Surgical decision making in premenopausal BRCA carriers considering risk reducing early-salpingectomy or salpingo-oophorectomy: a Qualitative Study

Abstract

Background: Acceptance of the role of the fallopian tube in “ovarian” carcinogenesis and the detrimental sequelae of surgical menopause in pre-menopausal women following risk-reducing-salpingo-oophorectomy (RRSO), has resulted in risk-reducing-early-salpingectomy with delayed-oophorectomy (RRESDO) being proposed as an attractive alternative risk-reducing strategy in women who decline/delay oophorectomy. We present the results of a qualitative-study evaluating the decision-making process amongst BRCA-carriers considering prophylactic-surgeries (RRSO/RRESDO) as part of the multicentre PROTECTOR-trial (ISRCTN:25173360). Methods: In-depth semi-structured 1:1 interviews conducted using a pre-developed topic-guide (development informed by literature review and expert consultation) until informational saturation reached. Wording and sequencing of questions were left open with probes used to elicit additional information. All interviews were audio recorded, transcribed verbatim, transcripts analysed using an inductive theoretical framework and data managed using NVIVO-v12. Results: Informational saturation was reached following twenty-four interviews. Seven interconnected themes integral to surgical decision-making were identified: fertility/menopause/cancer risk-reduction/surgical-choices/surgical-complications/sequence of ovarian-&-breast prophylactic-surgeries/support/satisfaction. Women for whom maximising ovarian-cancer risk-reduction was relatively more important than early-menopause/quality-of-life preferred RRSO, whereas those more concerned about detrimental impact of menopause chose RRESDO. Women managed in specialist familial-cancer clinic (FCC) settings compared to non-specialist settings felt they received better quality care, improved HRT-access and were more satisfied. Conclusion: Multiple contextual-factors (medical,physical,psychological,social) influence timing of risk-reducing surgeries. RRESDO offers women delaying/declining premenopausal-oophorectomy, particularly those concerned about menopausal effects, a degree of ovarian-cancer risk-reduction whilst avoiding early-menopause. Care of high-risk women should be centralised to centres with specialist familial gynaecological cancer risk management services to provide a better quality, streamlined, holistic multidisciplinary approach.