A controlled study of mental distress and somatic complaints after risk-reducing salpingo-oophorectomy in women at risk for hereditary breast ovarian cancer

Abstract

Objectives

Risk-reducing salpingo-oophorectomy (RRSO) provides effective protection against ovarian cancer in BRCA mutation carriers and in women at risk for hereditary breast ovarian cancer, but little is known about non-oncologic morbidity after the procedure. We explored mental distress and somatic complaints in women after RRSO compared to controls from the general population.

Methods

503 women from hereditary breast ovarian cancer families who had undergone RRSO after genetic counseling received a mailed questionnaire. 361 (71%) responded and 338 (67%) delivered complete data (cases). Controls were five randomly allocated age-matched controls per case (N  = 1690) from the population-based Norwegian Nord-Trøndelag Health Study (HUNT-2).

Results

Mean age of cases and controls was 54.6 years at survey. Mean time since surgery was 5.3 years (median 6.0). Compared to controls, the RRSO group had more palpitations (p  = 0.02), constipation (p  = 0.01), pain and stiffness (p  = 0.02), osteoporosis (p  = 0.02) and musculoskeletal disease (p  = 0.01) even after adjustments for demographic factors including use of hormonal replacement therapy. The RRSO group had lower levels of depression (p  < 0.001) and total mental distress (p  = 0.002) compared to controls. In multivariate linear regression analyses, RRSO was associated with lower levels of depression (p  < 0.001) and total mental distress (p  = 0.002).

Conclusions

In this controlled observational study, we found more somatic morbidity such as osteoporosis, palpitations, constipation, musculoskeletal disease and pain and stiffness but lower levels of mental distress among women who had undergone RRSO compared to controls.

Introduction

Ovarian cancer is the fifth most common cancer among women, and hereditary forms represent about 10% of cases [1]. The lifetime risk of ovarian cancer is about 40% for BRCA1 and 18% for BRCA2 mutation carriers, while the risk of sporadic ovarian cancer in the general female population is 1.7% [2]. Risk-reducing salpingo-oophorectomy (RRSO) reduces the risk of ovarian cancer by 80% and the risk of breast cancer considerably, but leads to an estimated 4% cumulative incidence of peritoneal cancer in 20 years after the procedure [3], [4], [5]. BRCA mutation carriers are counseled to perform RRSO before natural menopause, and in most cases, RRSO leads to surgical menopause [6].

Hot flashes and vasomotor symptoms are well known symptoms associated with estrogen deficiency in menopausal women [7]. Studies in post-RRSO samples have demonstrated more vasomotor symptoms and poorer sexual functioning compared to controls who chose ovarian cancer surveillance programs instead of RRSO [8]. The effect of the sudden onset of menopause on bowel function is not well-known, although at least one large study has assessed bowel habits in relation to age and gender [9]. Non-oncologic morbidity and especially somatic complaints are hardly studied in post-RRSO samples. However, a small study by Fry et al. [10] reported more aches and pains in women who had RRSO compared to women who remained in an ovarian cancer screening program. A recent longitudinal study of peri-menopausal Australian women with annual measurements showed a significant association between peri-menopause and aches and joint pain [11].

RRSO has been reported to be associated with a reduced fear of developing cancer, but also with a less favorable body image [12]. In a longitudinal study of 2500 middle-aged American women with an average risk of ovarian cancer, those with surgical menopause had significantly higher depression scores than women with natural menopause [13]. Madalinska et al. [8] examined a Dutch sample of women at high risk for ovarian cancer and compared those who had RRSO to those who had gynecological surveillance. They found that the RRSO group had less cancer worries than the surveillance group [8]. A prospective study by van Oostrom et al. [12] demonstrated that RRSO was associated with decreasing levels of anxiety in the short term. However, at 5 years follow-up, there was a trend towards increasing levels of anxiety, approaching the levels measured pre-surgery.

To the best of our knowledge, no studies have examined anxiety and depression levels after RRSO and compared the findings to that of age-matched controls from the general population using internationally validated instruments. In addition, few studies have addressed non-oncologic long-term morbidity in post-RRSO samples.

This study of a sample of Norwegian women who had RRSO due to BRCA mutation testing or pedigree evidence of hereditary breast ovarian cancer, had three aims: 1) to examine levels of mental distress and prevalence of somatic complaints compared to age-matched female controls from the general population. 2) To make internal comparisons of mental distress and somatic complaints in RRSO subgroups according to age at surgery and history of cancer. 3) To study the strength of associations between RRSO, BRCA mutation status, anxiety and total mental distress in the total sample (RRSO and control groups).