What is the role of prophylactic salpingectomy in reducing the risk of ovarian cancer for a female patient of reproductive age with BRCA1 or BRCA2 mutations or a strong family history of ovarian or breast cancer?

Prophylactic Salpingectomy in BRCA Mutation Carriers

Risk-reducing bilateral salpingo-oophorectomy (RRBSO), not salpingectomy alone, is the only recommended surgical approach for ovarian cancer prevention in reproductive-age women with BRCA1/2 mutations or strong family history of ovarian cancer. 1

Current Standard of Care

RRBSO remains the gold standard for ovarian cancer risk reduction in BRCA mutation carriers, reducing ovarian cancer risk by 80-90% and all-cause mortality by 77%. 1, 2 The procedure should include removal of both fallopian tubes and ovaries, as this provides proven mortality benefit. 1

Timing of RRBSO by Mutation Type

• BRCA1 carriers: Perform RRBSO at age 35-40 years after childbearing is complete 1
• BRCA2 carriers: Perform RRBSO at age 40-45 years after childbearing is complete 1
• Earlier timing should be considered if family history includes early-onset ovarian cancer 1

Why Salpingectomy Alone Is NOT Recommended

Risk-reducing salpingectomy (bilateral salpingectomy alone or with delayed oophorectomy) is explicitly NOT recommended outside clinical trial settings. 1 This is a critical distinction that must be emphasized to patients.

Evidence Gap for Salpingectomy Alone

• While the fallopian tube is recognized as the site of origin for most high-grade serous ovarian cancers, salpingectomy alone has never been proven to reduce ovarian cancer risk or mortality in BRCA carriers 3, 4
• Multiple ongoing prospective trials (WISP, PROTECTOR, SOROCk, TUBA) are investigating salpingectomy with delayed oophorectomy, but results are not yet available 1
• BRCA1 carriers face particularly high risk with earlier onset disease, making unproven strategies especially dangerous 1
• Salpingectomy alone should only be considered for women with lifetime ovarian cancer risk less than 5% (i.e., NOT BRCA carriers) 4

Surgical Approach

Minimally invasive laparoscopic surgery is the preferred approach for RRBSO, reducing morbidity, hospitalization time, and providing better aesthetic outcomes. 1, 5

Critical Pathology Protocol

• Specimens must be processed using the SEE-FIM protocol (Sectioning and Extensively Examining the FIMbriated End) 5
• Occult ovarian cancer is sometimes discovered at prophylactic surgery, emphasizing the need for meticulous pathologic review 1

Managing Consequences of Premature Menopause

Hormone replacement therapy (HRT) is essential after RRBSO in premenopausal women and should be continued until at least age 50-51 years. 1, 2

HRT Benefits and Safety

• Estrogen-only HRT is appropriate after hysterectomy and has a favorable safety profile 6
• HRT prevents cardiovascular disease, osteoporosis, cognitive dysfunction, and early mortality associated with premature surgical menopause 6, 2
• Short-term HRT does not decrease the overall breast cancer risk reduction benefit of RRBSO, particularly in BRCA2 carriers 2
• Failing to prescribe HRT after RRBSO in premenopausal women is a significant missed opportunity to prevent long-term morbidity 6

Timing-Specific Breast Cancer Risk Reduction

RRBSO provides additional breast cancer risk reduction beyond ovarian cancer prevention:

• Within 5 years post-surgery: Hazard ratio 0.28 for BRCA1 and 0.19 for BRCA2 7
• After 5 years: Hazard ratio 0.64 for BRCA1 and 0.99 for BRCA2 7
• For BRCA1 carriers undergoing RRBSO at age 40, cumulative breast cancer risk by age 70 is 49.7% versus 61.0% without RRBSO 7

Common Pitfalls to Avoid

• Do not offer salpingectomy alone as a risk-reduction strategy for BRCA mutation carriers—this is not evidence-based and exposes patients to unacceptable cancer risk 1, 3
• Do not assume RRBSO is risk-free—surgical risks include bowel, bladder, ureter, and vascular injury 1
• Do not withhold HRT after RRBSO in premenopausal women without contraindications—the cardiovascular and bone health consequences of premature menopause are severe 6, 2
• Do not routinely add hysterectomy to RRBSO unless other indications exist (Lynch syndrome, endometrial cancer risk factors, benign uterine pathology, or desire for estrogen-only HRT) 1

Additional Considerations

For women who previously underwent bilateral oophorectomy without salpingectomy, additional bilateral salpingectomy should be considered given the elevated fallopian tube cancer risk in BRCA carriers. 8