“Decisions on a Knife-edge”

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The Story

“Decisions on a Knife-edge”
by Charlotte Huff
Mosaic, March 10, 2015

The Pitch

Kill the Cancer: Save the Ovaries?

After two women on her father’s side died of ovarian cancer, Amy Starr wasn’t surprised to learn in 2010 that she carried a BRCA mutation, boosting her risk of one day developing the malignancy to 44 percent. But Starr was just 35 years old at that point, unsure if she wanted more children, and reluctant to prematurely launch into menopause by getting her ovaries removed.

Earlier this year, surgeons instead took out just her fallopian tubes, an experimental approach that’s now being studied at two U.S. medical centers through a trial launched last year. Researchers hope that the surgery will provide an intermediate path, reducing ovarian cancer risk at least somewhat for younger BRCA carriers like Starr who aren’t yet ready to let go of their fertility. “This is kind of a half step that I took this time,” says the 39-year-old Houston nurse. “I’d heard that it would possibly prevent cancer, would possibly give me some protection without having to go through menopause, which is terrible. It makes it easier to walk around and live your life from day to day.”

The surgery, which also is being pursued in several other countries, stems from a growing body of research which indicates that a surprising number of ovarian malignancies might begin growing in the nearby fallopian tubes. The intriguing hypothesis is based on the first wave of surgeries performed on BRCA carriers. Pathologists started finding cancers in the tubes as well as the ovaries, and sometimes just in the tubes themselves. At least 57% of malignancies
in BRCAcarriers, and at least 47% in women with ovarian cancer (but no BRCA mutation) might originate in the tubes based on genetic links and other pathology findings, according to a 2009 review in Gynecologic Oncology.

Some proponents of fallopian tube removal even argue that it might make sense, when women get their tubes surgically tied for reproductive reasons, to remove them instead for ovarian cancer prevention. In Canada, researchers with the British Columbia Ovarian Cancer Prevention
Project are pushing for all hysterectomies and tubal sterilizations to include tube removal, arguing that the additional step could cut ovarian cancer rates in half.

I’d like to write a piece for Mosaic that describes the procedure, the science behind it and the pros and cons of this experimental approach. Some critics worry that its use will proliferate beyond BRCA carriers, saying that tubal removal is not always a simple procedure and that more medical evidence of its relative benefits is needed first.

Study participants like Starr will have the option to get their ovaries removed later. Along with monitoring for the development of ovarian cancer, the study also will track how many women return later for ovary removal, says Dr. Karen Lu, a gynecologic oncologist at Houston’s M.D. Anderson Cancer Center and one of the researchers involved.

Yes, the traditional surgery—in which both the ovaries and fallopian tubes are taken out—can reduce ovarian cancer risk by at least 75 percent, studies show. But Lu says that tube removal, if it’s shown to provide some malignant protection, will provide a vital option for those younger women who are right now flatly refusing surgery rather than risk hot flashes, sexual difficulties and other menopausal symptoms. “They are forcing us as physicians to be much more creative and thoughtful about our recommendations,” she says.

Starr feels like she’s bought herself some time to mull over the next step. “The side benefit of that is I kind of got fixed,” says the mother of two, “and I lowered my cancer risk at the same time. There wasn’t a down side in my opinion.”

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