Why Might A Woman Have Her Ovaries Removed?

Megan Harlan Fleischut and Kenneth Offit

Genetic counselor Megan Harlan Fleischut and Clinical Genetics Service Chief Kenneth Offit help people understand their risk for ovarian, breast, and other types of cancer — key information for making medical decisions.

Actress Angelina Jolie Pitt continues to fuel a national dialogue on genetic testing and reducing the risk for ovarian and breast cancer in a March 24 op-ed in the New York Times. In the piece, she describes her decision to have her ovaries removed nearly two years after undergoing a double mastectomy to prevent breast cancer — a choice she had written about in 2013 — upon learning she carries a mutation in a gene called BRCA1.

The actress says that she and her doctors agreed that surgery to remove her ovaries and fallopian tubes was her best option “because on top of the BRCA gene, three women in my family have died from cancer.” The procedure, a laparoscopic bilateral salpingo-oophorectomy, revealed that she had a small benign tumor but no signs of cancer.

Ms. Jolie Pitt says knowing that she’d inherited gene mutations in BRCA1 and BRCA2, which are associated with an increased risk of breast and ovarian cancer, was critical in deciding to undergo both surgeries. BRCA1 was first discovered 20 years ago; BRCA2 followed later. Medical oncologist Kenneth Offit, Chief of Memorial Sloan Kettering’s Clinical Genetics Service, led the research team that identified the most common mutation in BRCA2.

Today, testing is available for mutations in BRCA2, as well as in BRCA1 and in other genes that have been linked to an increased risk for breast and ovarian cancer. Women can use the results of such genetic tests to make informed decisions — such as whether to surgically remove the ovaries (preventive oophorectomy) or breasts (preventive mastectomy) — to reduce their cancer risk.

In a 2014 interview, Dr. Offit noted that there have been great strides in prevention and early detection of breast cancer since the BRCA1 and BRCA2 mutations were identified. He encourages women and their families to take these factors into consideration when weighing their options.

Who should undergo genetic testing for ovarian or breast cancer?

It’s very important that women speak to their physicians if they have a personal history of breast cancer or close relatives who have had breast, ovarian, or prostate cancer, or some other types of cancer. Other strong risk factors include having had breast cancer at an early age (before age 50), having both breast and ovarian cancer, having a male relative with breast cancer, and being of Eastern European Jewish ancestry. In addition, all women with a personal history of ovarian cancer — regardless of their family history — should have BRCA testing.

While a significant number of women with breast cancer have a family history of the disease, only a small number may be advised to get genetic testing. Only about 5 to 10 percent of women with breast cancer will have an inherited risk of the disease due to BRCA mutations or other mutations.

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What is involved in getting tested?

Genetic testing is not just a blood test — it’s a process of genetic counseling that often involves the family. We like to see individuals with their sisters, their mothers, their significant others, both as a support and to enable women and their family members to make mutual decisions about screening and prevention.

Women meet with a genetic counselor to review all the options available should a test turn out to be positive, and also visit with a doctor to go over their family history of cancer and other risk factors in more detail. Only at that point is the actual test given (if a woman chooses to have it). Results take a few weeks to come back.

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What kind of information does genetic testing provide to women and their families?

If a woman tests positive for a BRCA mutation, she is not only at increased risk for breast cancer but also at increased risk for ovarian cancer. In fact, while the BRCA test is named after breast cancer, it is the ovarian cancer risk that we pay close attention to because we don’t have a means to screen for ovarian cancer to find it early, when it’s potentially curable.

When we first started doing genetic testing, we were very concerned about the negative impact that results might have. But we have found that genetic testing is in fact a very empowering experience both for women and their families, as there are now proven means for prevention and detection of some of the associated cancers.

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If a genetic test shows that a woman has an increased risk for breast or ovarian cancer, what are her options?

There are at least three options available upon testing positive for BRCA mutations. Surgery is one of them, and it’s the most effective means of breast cancer prevention. And while the surgical option for breast cancer is just that — an option — we strongly recommend surgical removal of the ovaries to reduce the risk of ovarian cancer for women who no longer expect to have children.

Doctors at MSK and other hospitals now have a very powerful means of screening for cancerous changes in the breast with magnetic resonance imaging, or MRI, which is more precise than mammography in finding early breast cancers. While most women in the United States choose screening over surgery, this is a discussion that needs to be individualized.

In addition, we can offer preventive treatment with drugs such as tamoxifen that for some women can cut the risk of breast cancer in half.

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Do you foresee any new advances in genetic testing for breast or ovarian cancer?

Up until now, we have only been able to tell a woman who tests positive for a BRCA mutation that her risk for developing cancer ranges from 40 to 90 percent. But over the last several years, researchers at MSK and elsewhere have discovered that there are genetic variations that will allow us to more closely pinpoint this risk. We hope to make these more-precise testing options available to women as part of our continued research.

Another research study now open at MSK involves testing for genes other than BRCA1 and BRCA2 in women with family histories of breast and/or ovarian cancer who have already tested negative for BRCA1 and BRCA2. In this study we offer a “panel” of tests for other genes (for example PALB2, CHEK2, etc.) that have more recently been discovered, and about which little is known regarding preventive care that is required. Individuals have the option in this study to get results only on genes they wish to learn about. As part of this research, there is no cost for the testing. Eventually, we anticipate that these panel tests will be more widely available and covered by insurance.

Finally, as part of longer-term research, we are also using next-generation DNA sequencing to discover new genes associated with hereditary risk for breast or ovarian cancer.

To make an appointment with our Clinical Genetics Service, call 646-888-4050.

To make an appointment with one of our breast cancer specialists, call 646-497-9064.

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I was diagnosed with fallopian tube cancer in 2005 and saw Dr. Tew for a second opinion. I am being treated by Dr. Chalas at Winthrop. I had a full hysterectomy and have had several rounds of chemo during the years and am BRAC2 positive. My sister, also BRAC2, has had fallopian tube and breast cancer. Thirteen of fifteen family members are positive for BRAC2. One sister and my daughter are the only ones who are negative. My question is should my daughter have her ovaries and possibly breasts removed since there is a high rate of BRAC2 in the family. Thank you for your response.

Phyllis, thank you for your question. Unfortunately, we can’t give personal medical advice on our blog. The decision about removal of breasts and/or ovaries involves a large number of factors. However, your daughter can contact our Clinical Genetics Service to learn about counseling and options: http://www.mskcc.org/cancer-care/hereditary-genetics/clinical-genetics-….

In evaluating family history, what does "close" relative mean who has been diagnosed with ovarian/breast cancer. How "close"? I know mothers, sisters are relevant, but what after that? Thank you

Gerri, when evaluating family history, both first-degree relatives (parents, children, and siblings) and second-degree relatives (grandparents, aunts, uncles, nieces and nephews) are important. To learn more about hereditary cancers, including how to make an appointment with our Clinical Genetics Service for consultation about your family history and cancer risks, you can go to: http://www.mskcc.org/cancer-care/hereditary-genetics. Thank you for your comment.