Risk-reducing salpingo-oophorectomy “is an important strategy for reducing both breast and gynecologic cancer risk for women with BRCA1 or BRCA2 mutations and is proven to improve life expectancy,” Noah D. Kauff, MD, told The ASCO Post. Questions persist, however, about whether women undergoing salpingo-oophorectomy should also have a hysterectomy to prevent later development of uterine ­cancer.

Dr. Kauff, who is Director of the Ovarian Cancer Screening and Prevention Program and Associate Attending Physician on the Clinical Genetics and Gynecology Services at Memorial Sloan-Kettering Cancer Center in New York, advises women with a family history of breast and ovarian cancer that they need to undergo genetic counseling to see whether genetic testing can help clarify that risk. Then, if they do elect risk-reducing surgery because of an inherited risk, “it is reasonable but not required to remove the uterus.” The decision should be based on a careful discussion of the pros and cons of including a hysterectomy with salpingo-oophorectomy.

Potential Benefits

As to the potential benefits of including hysterectomy, Dr. Kauff listed:

(1) It addresses the baseline risk of uterine cancer that all women have.

(2) There is a theoretical risk of cancer developing in the fallopian tube stump if the fallopian tubes and ovaries but not the uterus are removed. He stressed that the risk is only theorectical at this point and may not be a “real concern.”

(3) If the woman is at increased risk of high-grade uterine cancers, it also reduces that risk.

(4) It may simplify hormone replacement therapy, because if you remove the uterus, you can give estrogen alone as hormone replacement therapy, as opposed to giving the combination of estrogen and progesterone if a woman has a uterus in situ.

Dr. Kauff cautioned that it is not entirely clear that removing the uterus and then giving estrogen-alone hormone replacement therapy “is safer from a breast cancer standpoint than estrogen and progesterone hormone replacement. We have to be very careful about extrapolating data from the Women’s Health Initiative, which was conducted in asymptomatic women in their early 60s without an inherited predisposition, to women who are frequently in their mid to late 30s with an inherited predisposition. For this group, I don’t think it is clear that one approach to hormone replacement is safer than another. I just don’t think we have data on that at this point,” he said.

“There are reasons why you might lean toward removing the uterus,” he added. “For example, if you have been exposed to tamoxifen, there is an increased risk of uterine cancer even in the absence of a BRCA mutation, and that may be even greater in the presence of a BRCA mutation. That may ‘tip the scales’ toward having a hysterectomy.” Another reason, he noted, is “if there is other gynecologic pathology—for example, fibroids that are symptomatic, or if there is pelvic prolapse or urinary incontinence that requires a concomitant procedure. Sometimes that is easier to do with a hysterectomy at the same time.”

Potential Downsides

As to the potential downsides of including a hysterectomy with a salpingo-oophorectomy, Dr. Kauff pointed out:

(1) It is a bigger procedure.

(2) It is associated with a higher risk of complications. These complications are rarely life-threatening, but because we are operating near the nerves and tissues that affect not only the uterus, but also the bladder, the rectum, and the sexual organs, there can be immediate or long-term impact on bladder function, rectal function, or sexual function.

(3) Life-threatening complications are still rare, but they are a little bit more common with hysterectomy than without.

(4) Doing surgery on some of the pelvic support tissues may change the risk of pelvic prolapse and perhaps urinary incontinence in the future, but again, “the data on that are quite controversial,” Dr. Kauff said.

When all these factors are looked at together, “in the absence of other gynecologic indications, we think it is reasonable but not required to remove the uterus,” he concluded. ■