Is oophorectomy needed?

kikwit

I am writing on behalf of my friend, who lives in Ukraine.
She is 42 years old. Was diagnosed with IDC, ER+/PR+ HER2+.
Surgery: Lymph node removal, Mastectomy Left, Right
Chemotherapy 4 sessions, Radiation Therapy 14 sessions.
After the second session of radiation therapy she had no period for six months. And she got her period back this April. Now her doctor says that she needs oophorectomy. She has a child and she doesn't want to have children any more. But she is afraid of side effects of this surgery. She asked me to learn how does it work in US and Canada. She also hesitates because the surgery was scheduled and then postponed twice. It's like if it doesn't come to you maybe you don't need it.
So could you please explain if this surgery is really needed in my friend's situation.

farmerlucy

My sense from these boards is that some oncs suggest it in more aggressive cancers in younger women. Alternatively ovarian suppression is used in younger women who then can take an aromatase inhibitor instead of tamoxifen.

kikwit

Could you please explain me, why she needs oophorectomy or ovarian suppression after bilateral mastectomy?

BarredOwl

Hi kikwit:

"She is 42 years old. Was diagnosed with IDS, ER+/PR+ HER2+.
Surgery: Lymph node removal, Mastectomy Left, Right
Chemotherapy 4 sessions, Radiation Therapy 14 sessions. . .

. . . So could you please explain if this surgery is really needed in my friend's situation."

Unfortunately, we are not doctors, so we cannot answer your question.

". . . the surgery was scheduled and then postponed twice. It's like if it doesn't come to you maybe you don't need it. . .

Elective surgeries may be rescheduled. This does not mean that they are not needed. She cannot assume the surgery is not required or not recommended, merely because it was rescheduled.

Here is some general information.

As farmerlucy notes, clinical factors (e.g., age) and pathological features of disease that may indicate a higher risk of recurrence inform recommendations for more intensive approaches to endocrine therapy.

In general, initial endocrine therapy options may include one or more of the following, depending on various factors, such as type of cancer (e.g., DCIS, IDC), recurrence risk profile, and co-morbidities:

Pre-menopausal:

(a) Tamoxifen alone; or

(b) Tamoxifen plus Ovarian Suppression (to suppress/shut down ovarian function, e.g., with a second drug); or

(c) Ovarian Suppression ("OS") plus an Aromatase Inhibitor ("AI") (in pre-menopausal women, use of an AI requires added OS to shut down ovarian function; using both is intended to stop estrogen production from all sources)

If oophorectomy is received, see post-menopausal options

Post-menopausal (this includes patients whose ovaries have been removed by bilateral oophorectomy):

(a) Tamoxifen; or

(b) Aromatase inhibitor

Tamoxifen, aromatase inhibitors, and the drugs used to induce ovarian suppression have different side effect profiles. Oophorectomy has different health impacts. The choice between tamoxifen alone and other more intensive approaches is a personal risk/benefit analysis, that must be made in consultation with a Medical Oncologist ("MO") in light of one's risks of loco-regional and distant recurrence, risk of new disease, menopausal status, and overall health and presentation, including medical history or co-morbidities that may be potentially relevant to the particular side effect profiles of a specific drug or intervention. She should ask her MO and/or a second opinion MO to explain the more intensive approaches, their associated side effects, and obtain opinions about whether her specific case warrants the more intensive treatment(s), in light of her risk profile. If her MO is not responsive to her questions, she should not hesitate to seek a second opinion from another MO.

By training and experience, the MO should have an expert understanding of the available options, such as tamoxifen, an aromatase inhibitor, an ovarian suppression drug, and/or bilateral salpingo-oophorectomy ("BSO"). They should outline which options are suitable for her to consider, their potential benefits in terms of reducing recurrence risk, and their side effect profiles or risks. They should make a recommendation about which approach is best for her in their opinion, and why it is best. This will help her make an informed decision.

Genetic testing results may provide further information that are pertinent to personal risk of new disease. Certain genetic testing results (e.g., a pathogenic mutation in BRCA1, BRCA2, or other genes) and/or very strong family history of certain types of cancer may separately warrant consideration of "risk reduction surgery", such as oophorectomy.

BarredOwl

kikwit

BarredOwl, thank you very much for a such complete answer!

BarredOwl

Hi kikwit:

To your second question: The surgeon cannot remove every breast cell during mastectomy. Thus, even with mastectomy, there is a small risk of loco-regional recurrence (e.g., in the breast or regional lymph nodes).

In addition, mastectomy is a local treatment only. It removes the tumor. However, the tumor was in there a long time before it was removed. During that time, some tumor cells may have left the breast via the lymph and/or the bloodstream, and settled at distant sites, raising a risk of distant recurrence (i.e., metastatic recurrence). The risk of this having happened is greater with more agressive disease, such as HER2-positive disease and/or with lymph node involvement.

Systemic therapies, like chemotherapy, HER2-targeted therapy (if HER2-positive), and endocrine therapy (for hormone receptor-positive disease) are used to address the risk of distant recurrence.

Because she has hormone receptor-positive disease (in her case both estrogen receptor-positive (ER+) and progesterone receptor-positive (PR+) disease), she is a candidate for endocrine therapy.

As I explained above, with a greater the risk of distant recurrence, more intensive approaches to endocrine therapy may be warranted (e.g., ovarian suppression plus tamoxifen or an AI; or bilateral salpingo-oophorectomy plus tamoxifen or an AI).

BarredOwl

BarredOwl

Hi again, Kikwit:

Please note there is not enough information about her actual diagnosis, treatments received, on-going treatments, and personal medical history (including co-morbidities and results of any genetic testing and/or family history), to even have a layperson impression of whether the advice she received seems reasonably sound or not, based on our personal patient experiences.

You do not need to share any additional information with us. But it is important for your friend to know the answers to these questions, so she has a good understanding of her diagnosis, because it affects her risk profile and shapes the treatment advice she will receive.

For example, I don't know what "IDS" is. Did you mean to say that she has "invasive ductal carcinoma" ("IDC")?

Is she considered to have early stage invasive breast cancer (Stage I, II or III disease)?

I see she had bilateral mastectomy (left, right). Did she have bilateral disease? If not, what was the reason for removal of the second breast? Certain genetic test results and/or strong family history of certain cancers may lead to a recommendation for prophylactic mastectomy and prophylactic oophorectomy (specifically, bilateral salpingo-oophorectomy ("BSO")). In such a case, the BSO would also help reduce the risk ovarian and fallopian tube cancer.

I see she has post-mastectomy radiation, suggesting either lymph node involvement and/or small surgical margins.

What are the features of disease and nodal status (on each side if she has bilateral disease)?

What was the actual size of the tumor from the surgical pathology report? (T0, T1, T1a, T1b, T1c, T2, T3)

Was there any clinical evidence of lymph node involvement on either side?

What type of lymph node biopsy was done? (Sentinel node biopsy or other?)

What were the results of the lymph node biopsy (see surgical pathology report, N0, N1mi, N1, etcetera)? How many nodes were involved, and what was the extent of node involvement (isolated tumor cells? micrometastasis? macrometastasis?), if any.

As you may appreciate, the treatments received also affect residual recurrence risk and whether more intensive approaches to endocrine therapy may be indicated.

Did she receive any HER2-targeted therapy (trastuzumab, sold under the tradename HERCEPTIN))?

In the US and Canada, for IDC, even for the very smallest ER+PR+HER2+ tumors (Tumor ≤0.5 cm including microinvasive) and negative nodes ("N0"), some consideration would be given to adding HER2-targeted therapy (trastuzumab (HERCEPTIN)) to chemotherapy.

For ER+PR+HER2+ IDC where the Tumor is greater that 1 cm (in longest dimension) OR Node positive (one or more metastases >2 mm to one or more ipsilateral axillary lymph nodes), our local guidelines recommend:

=> Adjuvant chemotherapy plus trastuzumab followed by endocrine therapy (category 1)

She is pre-menopausal and "Now her doctor says that she needs oophorectomy." What type of "doctor" recommended oophorectomy? Is this their area of expertise?

A "medical oncologist" is a specialist whose training includes drug treatments for breast cancer, including the various approaches to endocrine therapy (using drugs and/or ovarian ablation methods such as surgery) in hormone receptor-positive breast cancer patients.

An expert in "medical genetics" (e.g., Genetic Counselor) should have specialized training in genetics and genetic and familial risk assessment, such that they can advise about inherited risk, genetic testing, genetic test results and what is known about any specific mutation found, and appropriate surveillance or risk-reduction surgeries, based on a person's complete risk profile.

A surgical gynecologist may know how to do the surgery, but may not have the required training that a medical oncologist or medical geneticist would have regarding whether the surgery is appropriate to consider or not. If the advice was from a gynecologist or surgical gynecologist (and not based on a gynecologic concern), further input should be sought from a medical oncologist. If genetic test results or suspicious family history of cancer are considerations, she should seek advice from a Genetic Counselor or other medical professional with medical genetics training.

What to do?

As I mentioned above, the best way to probe medical advice is to seek additional discussion and explanation from her medical oncologist, and/or to seek a second opinion about things such as:

(1) Please explain my recurrence risks, the purpose of endocrine therapy, and list all options for endocrine therapy that are suitable in my case;

(2) What are the risks and potential benefits of each suitable option, in light of my personal medical history? Do the potential benefits outweigh the possible risks?

(3) What exactly is the preferred or recommended approach in my specific case? Include a description of any proposed surgical treatments and continued drug treatments.

For example, are they recommending the removal of both ovaries and fallopian tubes by a "bilateral salpingo oophorectomy" ("BSO"), plus continued endocrine therapy with an aromatase inhibitor?

(4) Why it this approach preferred in my specific case over other options?

For example, why is BSO plus an aromatase inhibitor preferred to other approaches, such as ovarian suppression (with a drug) plus an aromatase inhibitor (a second drug)?

I hope this information can help your friend as she seeks additional information and advice about the treatment plan that is best for her.

BarredOwl

[Edited to add: "(and not based on a gynecologic concern)" ]

kikwit

BarredOwl, thank you!

It helps a lot. Thank you for explaining all this!