Systematic review of acceptability, cardiovascular, neurological, bone health and HRT outcomes following risk reducing surgery in BRCA carriers

• Published in: Best practice & research. Clinical obstetrics & gynaecology 2020-05, Vol.65, p.46-65
• Main Authors: Gaba, Faiza, Manchanda, Ranjit
• Format: Article
• Language: English
• Subjects: Acceptability; BRCA; Ovarian cancer; RRESDO; RRSO; Targeted surgical prevention
• ISSN: 1521-6934; 1532-1932
• DOI: 10.1016/j.bpobgyn.2020.01.006

Primary surgical prevention in the form of risk-reducing salpingo-oophorectomy (RRSO) is the most effective option and the gold standard for ovarian cancer (OC) risk-reduction, particularly given the absence of an effective national OC screening programme. However, premenopausal RRSO leads to premature surgical menopause with detrimental long-term health sequelae particularly in women who do not/are unable to take hormone replacement therapy (HRT). HRT uptake in women undergoing pre-menopausal oophorectomy appears low and is dependent on informed counselling, the safety of HRT and efficacy in mitigating the health sequelae of premature menopause. Acceptance of a central role for the fallopian tube in OC etiopathogenesis, coupled with the detrimental consequences of premature menopause, has led to the attractive proposal of early-salpingectomy with delayed oophorectomy as an alternative OC surgical prevention strategy in premenopausal women who have completed childbearing but decline or wish to delay RRSO. The successful implementation of risk reducing surgery for OC prevention depends on the acceptability of surgery to both, recipients (e.g. BRCA1/BRCA2 carriers) and intervention deliverers (healthcare professionals/researchers). Acceptability is also informed by an understanding of health outcomes following risk reducing surgery and the safety of HRT. It is therefore vital to understand the effects of surgery on important health outcomes such as cardiovascular health, neurological function and bone health. We present a comprehensive review of acceptability, the selected health outcomes mentioned above and HRT safety following risk reducing surgery. •Acceptability of surgical prevention of ovarian-cancer in BRCA-carriers is a dynamic concept.•Acceptability is influenced by counselling on health outcomes after surgery and HRT safety.•Premenopausal oophorectomy increases the risk of osteoporosis, heart-disease and neurocognitive-decline.•HRT use until natural-menopause mitigates risks and data supports safety of short term use in BRCA-carriers.