What is the management plan for a 32-year-old woman with a high-grade malignant breast mass, BRCA2 (Breast Cancer Gene 2) mutation, and history of ovarian cancer in her mother, currently scheduled to begin chemotherapy?

From the Guidelines

For this 32-year-old woman with newly diagnosed breast cancer and BRCA2 mutation, I recommend risk-reducing salpingo-oophorectomy (RRSO) between the ages of 35 and 40, or individualized based on the earliest age of onset of ovarian cancer in her family, as the most effective method for reducing ovarian cancer risk. This recommendation is based on the guidelines for genetic/familial high-risk assessment: breast and ovarian, which suggest that RRSO should be considered ideally between 35 and 40 years of age, or individualized based on the earliest age of onset of ovarian cancer in the family 1. Additionally, the ESMO clinical practice guidelines for cancer prevention and screening in BRCA mutation carriers and other breast/ovarian hereditary cancer syndromes recommend RRSO as the most effective measure for reducing the risk of ovarian cancer, and suggest that it should be carried out at age 35–40 1. The patient's family history of ovarian cancer and her BRCA2 mutation status increase her risk of developing ovarian cancer, making RRSO a crucial consideration for her care. It is also important to discuss the option of risk-reducing mastectomy with the patient, as well as the potential benefits and risks of chemoprevention options for breast and ovarian cancer 1. Regular follow-up and screening for breast and ovarian cancer, as well as counseling on reproductive desires and management of menopausal symptoms, should also be part of her comprehensive care plan. The use of oral contraceptives may be considered as a risk-reducing measure for ovarian cancer, as suggested by the ESMO guidelines 1, but the primary recommendation for this patient would be RRSO. Overall, the goal of these recommendations is to reduce the patient's risk of developing ovarian and breast cancer, while also considering her reproductive desires and overall quality of life.

From the Research

Patient's Condition and Treatment

• The patient is a 32-year-old woman with a history of multiple pregnancies and a recent miscarriage.
• She has been diagnosed with high-grade malignant breast cancer and is scheduled to begin chemotherapy.
• The patient has a family history of ovarian cancer, with her mother dying from the disease at age 50, and has been found to have a mutation in the BRCA2 gene.
• She has been advised to avoid pregnancy during chemotherapy.

Contraception Options

• The patient has previously used oral contraceptive pills without adverse effects.
• The use of intrauterine devices (IUDs) has been studied in relation to cancer risk, with some evidence suggesting that both levonorgestrel-releasing and copper IUDs may reduce the risk of endometrial and ovarian cancer 2.
• However, there is limited evidence on the safety of IUD use among women with ovarian cancer, with one systematic review finding no data to suggest that IUD use would lead to worsening of primary ovarian cancer 3.

Chemotherapy and Fertility

• Chemotherapy is a widely recognized form of cancer treatment that uses cytotoxic drugs to kill cancer cells and prevent their reproduction 4.
• The goals of chemotherapy can be curative, palliative, or adjunctive, and combination chemotherapy is commonly prescribed.
• Chemotherapy can have various side effects, including fatigue, nausea, vomiting, and hair loss, as well as increased risk of infection and inflammation of organs such as the heart, lungs, and liver.

Timing of Chemotherapy

• The optimal timing of chemotherapy in breast cancer is unclear, but increased time-to-chemotherapy (TTC) may have a negative prognostic impact, and delays beyond 4 weeks should be avoided 5.
• The patient's chemotherapy schedule should be determined by her healthcare provider, taking into account her individual needs and medical history.

HIV-1 Risk and Contraceptives

• Some observational studies suggest that certain contraceptives, such as the long-acting injectable progestin contraceptive, may increase the risk of HIV-1 acquisition.
• However, a study on the effects of levonorgestrel-containing IUDs, copper IUDs, and levonorgestrel-containing oral contraceptives on susceptibility to HIV-1 found no association between these contraceptives and increased rates of HIV-1 entry into female reproductive tract cells 6.