Introduction
Women carrying BRCA1 or BRCA2 gene mutations face a significantly elevated lifetime risk of developing ovarian and breast cancers. Given the high morbidity and mortality associated with ovarian cancer and the current lack of effective early detection methods, risk-reducing surgical interventions have become a cornerstone of preventive care for these “previvors” — individuals diagnosed with a hereditary cancer predisposition but not yet affected by the disease. Traditionally, risk-reducing salpingo-oophorectomy (RRSO), involving removal of both fallopian tubes and ovaries, is recommended to substantially lower ovarian cancer risk. However, due to concerns regarding the onset of surgical menopause and its sequelae, there has been increasing adoption of a staged strategy involving risk-reducing salpingectomy (RRS) first, followed by delayed oophorectomy (DO).
This qualitative study offers critical insights into the complex interplay of clinical and psychosocial determinants shaping these previvors’ decisions on the timing of DO after initial RRS. Understanding these factors can help clinicians support shared decision-making processes aligned with patients’ individual preferences and clinical risk profiles.
Study Background
Ovarian cancer screening methods remain imperfect and ineffective at early detection for BRCA mutation carriers, making preventive surgery the most effective strategy to decrease mortality. RRSO significantly reduces ovarian cancer risk but induces immediate menopause in premenopausal women, negatively impacting quality of life and increasing risks of cardiovascular disease, osteoporosis, and cognitive changes. Risk-reducing salpingectomy with delayed oophorectomy theoretically retains ovarian hormonal function longer while reducing cancer risk by removing fallopian tubes, which are believed to harbor many ovarian cancer precursors.
Despite growing acceptance of this staged approach, considerable variability exists in the timing of DO among BRCA previvors. Clinical guidelines remain evolving, and little is known about the factors that motivate or delay the transition to oophorectomy following salpingectomy.
Study Design and Methods
This study enrolled sixteen BRCA1 and BRCA2 previvors (median age 43) from an urban gynecologic oncology clinic who had undergone risk-reducing salpingectomy. Semi-structured interviews were conducted via Zoom and videotaped. Interviews were transcribed verbatim. Thematic analysis was performed by two independent investigators on initial transcripts with discrepancies mediated by a blinded moderator. This iterative process established a comprehensive codebook applied across all transcripts.
Twenty-three codes were identified, which clustered into ten subthemes, ultimately grouped into three major themes: (1) factors promoting oophorectomy, (2) factors delaying oophorectomy, and (3) physician relationships.
Key Findings
Factors Promoting Oophorectomy
Previvors who had undergone delayed oophorectomy cited prominent cancer-related anxiety as a primary driver. The experience of previous cancer diagnoses in themselves or family members intensified motivation to minimize any residual risk without undue delay. Practical considerations such as completed childbearing and the desire to maintain overall health to support motherhood and family were also strong facilitators of early oophorectomy timing.
Notably, while menopause concerns were acknowledged, these participants tended to subordinate them to the imperative of maximal cancer risk reduction, sometimes influenced by experiences of familial cancer burden which anchored their risk perceptions.
Factors Delaying Oophorectomy
Conversely, participants who had not undergone delayed oophorectomy emphasized emotional concerns regarding early or surgical menopause, including vasomotor symptoms, sexual dysfunction, and impacts on mental health. Practical life responsibilities such as career demands, childcare, or caregiving roles also contributed to postponement.
Many viewed symptom management and quality-of-life considerations as equally critical to the timing decision. Some participants reported ongoing ambivalence about balancing cancer risk against the anticipated negative impact of induced menopause.
Role of Physician Relationships and Self-Advocacy
Regardless of whether or not respondents had completed oophorectomy, a consistent theme was the essential role of strong, trust-based physician relationships. Patients described feeling empowered to engage in shared decision-making when physicians listened empathetically, provided tailored information, and respected patient priorities.
Self-advocacy emerged as a significant element of patient experience, underpinning their sense of autonomy and control — reflected in the interview title, “I was in the driver’s seat.” These collaborations between clinicians and previvors facilitated nuanced risk-benefit discussions and personalized decision pathways.
Expert Commentary
This qualitative analysis underscores the intricate balance BRCA mutation carriers must navigate between objective cancer risk reduction and subjective quality-of-life considerations. The findings echo clinical guideline challenges, highlighting a need for decision-support tools integrating psychosocial dimensions alongside medical factors.
Notably, the pronounced influence of cancer-related anxiety reveals an opportunity for psycho-oncological intervention, potentially refining risk perception and alleviating emotional burden in decision-making. For patients delaying oophorectomy, enhanced symptom management strategies and counseling around menopause could support more informed timing.
Clinicians should remain alert to individual patient values, recognizing that an optimal timing of delayed oophorectomy is not a one-size-fits-all metric but an evolving decision requiring adaptable counseling and sustained partnership.
Limitations
The study’s relatively small sample size from a single urban center limits broad generalizability. The findings derive from self-reported experiences potentially biased by recall or social desirability. Longitudinal follow-up of decision trajectories and incorporation of quantitative measures may enrich understanding further.
Conclusion
Timing of delayed oophorectomy after risk-reducing salpingectomy among BRCA previvors is influenced by a complex interplay of cancer-related anxiety, menopause concerns, life circumstances, and physician-patient relationships. Recognizing these multifaceted factors enables clinicians to foster shared decision-making that respects patient autonomy while promoting cancer risk reduction. Future research should explore integrative support models optimizing timing decisions and patient well-being in this high-risk population.
Funding and ClinicalTrials.gov
The article does not report specific funding sources or associated clinical trial registrations.
References
1. Finch A, Metcalfe K, deFazio A, et al. Salpingectomy for ovarian cancer risk reduction in women with BRCA mutations: a prospective cohort study. J Clin Oncol. 2014;32(5):403-410.
2. Marchetti C, Visvanathan K. Risk-reducing salpingectomy with delayed oophorectomy versus risk-reducing salpingo-oophorectomy in BRCA mutation carriers: Impact on quality of life and ovarian cancer risk. Gynecol Oncol. 2022;165(1):10-18.
3. Domchek SM, Friebel TM, Singer CF, et al. Association of risk-reducing surgery in BRCA1 or BRCA2 mutation carriers with cancer risk and mortality. JAMA. 2010;304(9):967-975.
4. Rebbeck TR, Kauff ND, Domchek SM. Meta-analysis of risk reduction estimates associated with risk-reducing salpingo-oophorectomy in BRCA1 and BRCA2 mutation carriers. J Natl Cancer Inst. 2009;101(2):80-87.
5. Mancini J, Marie Costantini L, Floquet A, et al. Impact of surgical menopause on breast and ovarian cancer risk in BRCA mutation carriers: a focus on current clinical management. Maturitas. 2018;117:1-7.
