Prophylactic Surgery in the General Population

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Prophylactic surgery for ovarian cancer encompasses several procedures. Bilateral salpingo-oophorectomy with removal of both the fallopian tubes and the ovaries is often advocated for the prevention of ovarian cancer. The procedure may be performed through an open or laparoscopic approach. All peritoneal surfaces should be examined. The procedure should result in the removal of the entire ovary and all but the intramural portion of the fallopian tube. The ovarian vessels should be clamped approximately 2 cm proximal to the ovary to reduce the risk of retained ovarian tissue. All adhesions should be excised. In addition to operative risk, reproductive-age women face surgical menopause after prophylactic oophorectomy. Both bilateral tubal ligation and hysterectomy without removal of the tubes and ovaries have also been shown to reduce the risk of subsequent ovarian cancer. Hysterectomy along with bilateral salpingo-oophorectomy has been advocated by some groups to remove the intramural portion of fallopian tube, which may be at risk for malignant transformation.

The incidence of ovarian cancer in the general population is sufficiently low that oophorectomy is not recommended when there is no other indication for surgery. However, given the minimal impact of prophylactic oophorectomy on morbidity, its role at the time of hysterectomy has been explored. Averette and Nguyen19 estimated that approximately 300 prophylactic oophorectomies would have to be performed at the time of hysterectomy in women over the age of 40 to prevent one case of

Table 4-4. Ovarian Cancer Risk Reduction: Surgery in the General Population

Investigation Surgery Odds Ratio 95% CI

0.38-0.93 0.62-1.2 0.50-0.86 0.72-1.1 0.16-0.64 0.45-1.00

*Meta-analysis of case control investigations utilizing controls from hospitals.

+Meta-analysis of case control investigations utilizing controls from random digit dials of case neighborhoods. **Prospective investigation. BTL, bilateral tubal ligation.

Whittemore et al6 BTL 0.59*

Whittemore et al6 BTL 0.87+

Whittemore et al6 Hysterectomy 0.66*

Whittemore et al6 Hysterectomy 0.88+

Hankinson et al20 BTL 0.33**

Hankinson et al20 Hysterectomy 0.67**

ovarian cancer. Several assumptions were used to arrive at this number. The investigators used an annual incidence of 24,000 new cases of ovarian cancer and estimated that 5% to 14% of these women had previous hysterectomy with conserved ovaries. Approximately 50% of these women were over 40 at the time of hysterectomy. Therefore, about 1000 cases of ovarian cancer in the United States could be prevented with diligent practice of prophylactic oophorectomy. Assuming approximately 300,000 opportunities to perform prophylactic oophorectomy in the United States annually, the authors arrive at their estimate of 300 prophylactic oophorectomies to prevent one case of ovarian cancer in the general population.

The issue of prophylactic oophorectomy should at least be discussed with patients who are undergoing hysterectomy over the age of 40. However, the benefits are modest and must be considered against the implications of surgical menopause. Patients need to be aware that they continue to face a small risk of primary peritoneal cancer despite removal of both ovaries.

Both bilateral tubal ligation and hysterectomy appear to reduce ovarian cancer risk without causing surgical menopause. These procedures, however, should not be performed solely for the reduction in ovarian cancer risk. In their investigation incorporating 12 U.S. case-control studies, Whittemore and colleagues6 reported that both tubal ligation and hysterectomy result in reduced risk of ovarian cancer. Using a prospective cohort design, Hankinson and coworkers20 followed 121,700 female nurses prospectively. After controlling for ovarian cancer risk factors, a strong inverse association was reported between tubal ligation and ovarian malignancy with a relative risk of 0.33 and 95% CI of 0.16 to 0.64. A weaker inverse association was noted between hysterectomy and ovarian cancer with a relative risk of 0.67 and 95% CI of 0.45 to 1.00.

Bilateral salpingo-oophorectomy, tubal ligation, and hysterectomy all appear to reduce the risk of ovarian cancer in the general population. However, given the overall low incidence of this malignancy, hundreds of prophylactic procedures need to be performed to prevent one case of cancer of the ovary. Because of the risks associated with surgery, these procedures are not recommended in the general population with prophylaxis as the sole indication (Table 4-4).

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