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medpundit |
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Wednesday, May 22, 2002When I heard this story, my first reaction was a knee-jerk anti-male-medical-establishment rejection of it worthy of Jane Fonda and the Our Bodies ,Our Selves crowd. After all, no one ever suggests that men have their testicles removed to save them from future prostate cancer. But then, I gave it a little more thought, and my feelings about it softened. After all, the studies only look at women with specific gene mutations that put them at higher than average risk of breast cancer and ovarian cancer. It isn’t quite the “those organs are bound to get cancer some day anyway, so you might as well take them out.” approach to hysterectomy and oophorectomy that I heard so often as a medical student from older (male) surgeons and gynecologists. It isn’t quite that, but it’s close. The BRCA1 and BRCA2 gene mutations do increase the risk of getting ovarian or breast cancer. They do not predestine the carrier to having the disease. The BRCA1 mutation increases the lifetime risk of breast cancer to 50-85%, and the lifetime risk of ovarian cancer to 20-40%. Those are wide ranges. That means we aren’t sure exactly by how much the risk is increased, but that it is significantly increased. Similary, the BRCA2 mutation increases the risk of breast cancer to 50-85% and the risk of ovarian cancer to 10-20%. The studies in question took samples of women who tested positive for either of these mutations. They then offered them the choice of surveillance or of total oophorectomy. In one of the studies, the women were divided into a group of 98 women who had their ovaries removed and 72 women who didn’t. The sans ovary group had three women (3%) who developed breast cancer within two years of follow-up. The surveillance group had eight women (11%) who developed breast cancer in the same time frame. Four of the women who kept their ovaries went on to develop ovarian cancer. The other study looked at more women over a longer period of time, but concentrated more on the risk of ovarian cancer. It compared 259 women who had already had an oophorectomy to a group of 292 women who still had their ovaries. Both groups had mutations in the BRCA1 or BRCA2 gene. Six women (2.3%) who had their ovaries removed were discovered to have undetected ovarian cancer at the time of surgery. Two women (0.8%) developed peritoneal cancer, a cancer of the lining of the abdominal wall and outer bowels that could be caused by wayward ovarian cancer cells. They were not the same women who were diagnosed with undetected cancer at the time of their surgery. In the surveillance group 58 (20%) developed ovarian cancer within eight years. The study doesn't say if any of them developed peritoneal cancer. Interestingly, they also looked at a subgroup of patients regarding the risk of breast cancer. They had to exclude patients who had previously had a mastectomy or had a personal history of some sort of breast cancer when the study was begun. That left them with a group of 99 women who had no ovaries, and 142 women who still had them. Of these two groups, 21 women (21%) in the sans ovary group developed breast cancer, and 60 (42%) in the control group developed it. In both studies, the majority of women did not go on to develop breast or ovarian cancer even if they kept their ovaries. An accompanying editorial in the New England Journal of Medicine comes down in favor of bilateral oophorectomy to reduce the risk of breast cancer in carriers of these two mutations. That’s fine, as long as the doctor who is doing the recommending makes it clear that oophorectomy isn’t entirely benign and that it’s not a foregone conclusion that a woman with the gene mutations is going to develop breast cancer. Nor is taking out the ovaries a guarantee that she will not develop breast cancer at some point. It only reduces the risk that she will. Removing the ovaries increases the risk of cardiovascular disease and osteoporosis. It can cause hot flashes, sexual dysfunction, weight gain, and sometimes a general sense of overall unwellness. Not everyone experiences this, but a significant number of women complain that they “just don’t feel like themselves” afterward. For some women, it may be worth it to eliminate the chance of developing ovarian cancer, or to reduce the risk of developing breast cancer. That choice, however, is a highly personal one, and it should be made with a full and complete understanding of its risks and benefits. posted by Sydney on 5/22/2002 09:52:00 AM 0 comments 0 Comments: |
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