[Physician Comment] BRCA test results predict utilization of bilateral risk-reducing salpingo-oophorectomy

Feb 3rd – JAMA – In spite of limited evidence for their use in this population, a substantial portion of women with uninformative BRCA test results chose to undergo RRSO and ovarian cancer screenings.

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1. In spite of limited evidence for their use in this population, a substantial portion of women with uninformative BRCA test results chose to undergo RRSO and ovarian cancer screenings.

2. Positive BRCA 1 or 2 status was a strong predictor for undergoing subsequent ovarian cancer screenings and bilateral, risk-reducing salpingo-oophorectomy (RRSO).

The results of this study show that BRCA test result (positive, negative or uninformative) is predictive of patient utilization of ovarian cancer screenings (CA-125, TVUS) and risk-reducing procedures (RRSO). In this study, women with a positive BRCA test result were much more likely to undergo screenings and salpingo-oophorectomies, while women with negative BRCA results were unlikely to do so. Despite limited evidence that screenings and RRSO’s lower morbidity in this population, more than a third of women with uninformative BRCA results chose to undergo ovarian cancer screenings and over 12% underwent RRSO.

This study has a number of limitations. Because women with a greater interest in ovarian cancer are more likely to complete this survey, the results of this study may be subject to selection bias. While the study population was diverse, the generalizability of this study’s results may be limited due to variations in patient and physician attitudes toward screening and risk management, which may have changed since the study period ended 5 years ago. Further exploration of what drives patient decisions to elect for screenings and RRSO, including pairing family history with BRCA results, would provide useful insight into how to revise guidelines and improve patient education and expectation management.

Click to read the study in the current issue of JAMA

Click to read an accompanying editorial in JAMA

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1. In spite of limited evidence for their use in this population, a substantial portion of women with uninformative BRCA test results chose to undergo RRSO and ovarian cancer screenings.

2. Positive BRCA 1 or 2 status was a strong predictor for undergoing subsequent ovarian cancer screenings and bilateral, risk-reducing salpingo-oophorectomy (RRSO).

Study author Gabriel N. Mannis, M.D. talks to to 2 Minute Medicine: Clinical Fellow in Hematology/Oncology at UCSF

“The key finding of this study is that the vast majority of women referred for testing–over 70%–receive uninformative results, and that despite a lack of guidelines for these women, a substantial percentage of them went on to have screening tests or prophylactic surgeries. These findings highlight the need for further cancer-risk stratification in a significantly understudied population whose cancer risk is likely quite heterogeneous. On a broader level, these findings highlight that with any cancer screening program, a negative test does not always allay patient fears and physicians must play a key role in discussing the potential risks and benefits of any screening test with their patients.”

This [retrospective cohort] study compared rates of ovarian cancer screening and risk-reduction procedures post-BRCA testing at two hospital sites. Authors surveyed 1077 women who were BRCA tested from 1996-2008, divided them into groups by test result (positive, negative or uninformative) and assessed utilization of ovarian cancer screenings (serum cancer antigen 125 (CA-125) and transvaginal ultrasonography, TVUS) and RRSO.

Women who tested positive for BRCA mutations (1 or 2) were more likely to undergo ovarian cancer screenings via serum CA-125 (OR 13.0; CI 5.5-29.0) and TVUS (OR 9.5, CI 4.3-21.0) and much more likely to elect for a risk-reducing bilateral salpingo-oophorectomy (RRSO) (OR 28.1; CI 16.2-48.6). Women with a negative BRCA result were unlikely to undergo these procedures. Despite receiving an uninformative BRCA test results, 12.3% of women reported undergoing RRSO. Additionally over a third of women with uninformative test results reported undergoing screenings via serum CA-125 and TVUS (33.8% and 37.3%, respectively).

In sum: The results of this study show that BRCA test result (positive, negative or uninformative) is predictive of patient utilization of ovarian cancer screenings (CA-125, TVUS) and risk-reducing procedures (RRSO). In this study, women with a positive BRCA test result were much more likely to undergo screenings and salpingo-oophorectomies, while women with negative BRCA results were unlikely to do so. Despite limited evidence that screenings and RRSO’s lower morbidity in this population, more than a third of women with uninformative BRCA results chose to undergo ovarian cancer screenings and over 12% underwent RRSO.

This study has a number of limitations. Because women with a greater interest in ovarian cancer are more likely to complete this survey, the results of this study may be subject to selection bias. While the study population was diverse, the generalizability of this study’s results may be limited due to variations in patient and physician attitudes toward screening and risk management, which may have changed since the study period ended 5 years ago. Further exploration of what drives patient decisions to elect for screenings and RRSO, including pairing family history with BRCA results, would provide useful insight into how to revise guidelines and improve patient education and expectation management.

Click to read the study in the current issue of JAMA

Click to read an accompanying editorial in JAMA

By Denise Pong and Leah Hawkins

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