Is it common for a 35-year-old female with BRCA (Breast Cancer Gene) positivity to have her ovaries removed as a preventive measure, without undergoing a mastectomy?

Risk-Reducing Salpingo-Oophorectomy in BRCA-Positive Women

Yes, it is absolutely standard and recommended practice for a 35-year-old BRCA-positive woman to undergo risk-reducing bilateral salpingo-oophorectomy (RRBSO) without necessarily having a mastectomy—these are independent risk-reduction decisions that should be made separately based on different timelines and patient preferences. 1

Why RRBSO is Standard Practice

RRBSO is the single most effective intervention for ovarian cancer prevention in BRCA carriers, reducing ovarian/fallopian tube cancer risk by 80-90% and decreasing all-cause mortality by 77%. 1, 2 This mortality benefit makes it a cornerstone of BRCA management. 1

The procedure should include removal of both ovaries AND fallopian tubes, as many ovarian cancers actually originate in the fallopian tubes. 1, 2

Recommended Timing by Mutation Type

The timing differs significantly based on which BRCA mutation your patient carries:

• BRCA1 carriers: RRBSO recommended at age 35-40 after childbearing is complete 1, 2, 3
• BRCA2 carriers: RRBSO recommended at age 40-45 after childbearing is complete 1, 2

This age difference reflects the natural history of ovarian cancer in these populations—BRCA2-associated ovarian cancers occur approximately 8-10 years later than BRCA1-associated cancers. 1 Among BRCA1 carriers, the incidence of occult ovarian cancer at RRBSO was 1.5% before age 40 and 3.8% for ages 40-49, whereas BRCA2 carriers have only 1% risk before age 50. 1

Why Mastectomy is a Separate Decision

RRBSO and mastectomy address different cancer risks and follow different timelines. 4, 2 Here's the key distinction:

Breast Cancer Management Options

BRCA carriers have two primary approaches for breast cancer risk:

1. Intensive surveillance (without mastectomy):

   • Annual breast MRI starting at age 25 4, 2
   • Annual mammography starting at age 30 4, 2
   • Clinical breast examination every 6-12 months starting at age 25 4, 2

2. Risk-reducing bilateral mastectomy:

   • Can be considered starting at age 25 4
   • Most effective method for reducing breast cancer risk 4
   • Timing should consider completion of childbearing and breastfeeding 4

Many BRCA carriers choose surveillance over mastectomy, making your patient's decision entirely reasonable and common. 4 The surveillance protocol is robust and allows for early detection while preserving native breast tissue.

Why RRBSO Takes Priority

Unlike breast cancer where effective surveillance exists, there is no effective screening for ovarian cancer that reduces mortality. 1, 2 While 6-monthly transvaginal ultrasound and CA-125 can be offered from age 30 until RRBSO, these have limited effectiveness and do not prevent deaths. 1, 2 This makes surgical prevention far more critical for ovarian cancer than for breast cancer.

Important Counseling Points

Residual Risks

Even after RRBSO, there remains a small (<5%) residual risk of primary peritoneal carcinoma. 5, 6 This should be explained but should not deter the procedure given the substantial overall benefit.

Menopausal Management

Your patient will experience surgical menopause at age 35, which requires careful management:

• Hormone replacement therapy (HRT) is safe and recommended until the natural age of menopause (~50-51 years) to mitigate bone loss, cardiovascular risks, and menopausal symptoms. 7, 8
• Estrogen-only HRT appears protective against breast cancer in BRCA carriers and does not increase risk. 8
• Estrogen-plus-progestogen HRT shows no significant increase in breast cancer risk. 8
• Short-term HRT does not negate the cancer risk reduction benefits of RRBSO. 7

Hysterectomy Consideration

Hysterectomy is NOT routinely recommended at the time of RRBSO unless other indications exist (such as Lynch syndrome genes, endometrial cancer risk factors, or benign uterine pathology). 1 However, some carriers choose concurrent hysterectomy to enable estrogen-only HRT, which has a more favorable breast cancer risk profile. 1

Common Clinical Pitfalls to Avoid

• Don't delay RRBSO beyond recommended ages based on mutation type—the cumulative risk rises significantly with each passing year, particularly for BRCA1 carriers. 3
• Don't pressure patients into mastectomy when they choose RRBSO—these are independent decisions with different risk-benefit profiles. 4
• Don't withhold HRT after RRBSO due to breast cancer concerns—recent evidence shows estrogen-only HRT may actually be protective. 8
• Don't forget fertility counseling—ensure childbearing is complete before RRBSO, and discuss fertility preservation options if needed. 1, 2

Bottom Line for Your Patient

Your 35-year-old BRCA-positive patient made an evidence-based, guideline-concordant decision to undergo RRBSO without mastectomy. This is extremely common practice. She should continue intensive breast surveillance with annual MRI and mammography, and she should be offered HRT to manage surgical menopause symptoms and long-term health risks. 4, 2, 7