Abstract
To evaluate the intention of women at high risk for breast and ovarian cancer to undergo risk-reducing salpingo-oophorectomy (RRSO) after genetic testing, and to identify the main factors related to their decision-making. A prospective cohort study conducted at the high-risk outpatient clinic of the State University of Campinas (UNICAMP), including 355 high-risk women followed between November/2021 and October/2022. Participants answered clinical and sociodemographic questionnaires, underwent comprehensive genetic testing, and received pre- and post-test genetic counseling. The majority were white (60.3%), younger than 50 years (71.5%) with a mean age of 43 years, and premenopausal (61.6%). 355 patients were tested and 102 (28,7%) carried likely pathogenic or pathogenic variants, 59,3% in the BRCA 1 and 2 genes. Before testing, 42.5% expressed the intention to undergo RRSO, which decreased to 33.4% after counseling (p < 0.05). The pre-test desire was more frequent in women aged 40–49 years, premenopausal, and with higher education (p < 0.05). In multiple regression, the desire for risk-reducing mastectomy (OR ≈ 39, 95% CI 16,8–90,79, p < 0,0001), the presence of pathogenic variants in BRCA (OR 15,46, 95% CI 6.05–39.53, p < 0,0001), and a personal history of cancer (OR 2,69, 95% CI 1.52–4.75, p < 0,0001) were independently associated with the intention to undergo RRSO. Intention to undergo risk-reducing salpingo-oophorectomy was higher among younger and premenopausal women and those with higher educational attainment and was strongly associated with the desire to undergo risk-reducing mastectomy and a personal history of breast or ovarian cancer. Changes in intention after genetic testing reflected gene-specific risk stratification: intention was withdrawn predominantly among women without high-penetrance BRCA variants, whereas it was adopted primarily among those carrying pathogenic variants in high-risk genes. These findings underscore the importance of access to germline genetic testing to support individualized, risk-informed decision-making regarding high-complexity preventive strategies.
Supplementary Information
The online version contains supplementary material available at 10.1038/s41598-026-40036-1.
Keywords: Risk-reducing salpingo-oophorectomy, BRCA1, BRCA2, Genetic counseling, Breast cancer, Ovarian cancer
Subject terms: Cancer, Diseases, Health care, Medical research, Oncology, Risk factors
Introduction
Women with a hereditary predisposition to breast and ovarian cancer face significantly elevated lifetime risks of developing these malignancies. This risk is particularly high for those carrying likely pathogenic (LPV) or pathogenic variants (PV) in the BRCA1 and BRCA2 genes. A prospective cohort study of over 9,000 women with PV/LPV in BRCA1 or BRCA2 estimated their cumulative ovarian cancer risk by age 80. The risk was 44% for BRCA1 and 17% for BRCA2 carriers, with the increase occurring mainly after age 601.
Risk-reducing salpingo-oophorectomy (RRSO) is widely recognized as the main strategy for preventing ovarian cancer in high-risk women, reducing the incidence of this malignancy by over 70%2and reducing the risk of breast cancer by up to 64%2–5. It is generally indicated between 35 and 45 years of age. Furthermore, studies demonstrate the impact of this procedure on survival, as it is associated with a reduction in all-cause mortality and specific breast cancer mortality in women with PV/LPV in BRCA1 or BRCA2, without increased ischemic heart and cerebral diseases, or depression6. While some studies suggest no substantial increase in cardiovascular events, others indicate a higher risk following premature menopause, particularly among women who do not receive hormone replacement therapy6,7.
Adherence to RRSO varies widely, with rates between 25% and 70% among eligible women, even after genetic counseling8. The main concerns include adverse effects of premature menopause, such as sexual dysfunction, cardiovascular risk, osteoporosis, cognitive changes, and psychological impact9. These factors can negatively influence the decision to undergo RRSO, despite a clear clinical indication.
Despite the oncological benefits, the decision regarding risk-reducing surgeries is complex and is influenced by factors such as age, parity, presence of pathogenic variants, genetic counseling, individual risk perception, and sociocultural and psychological factors. A study involving 571 women at high risk for ovarian cancer demonstrated that RRSO was more frequently performed in women who had already had children, knew they carried PV/LPV in high-risk genes, or had a mother or sister who died from ovarian cancer10.
While most studies have focused on women carrying pathogenic variants in high-penetrance genes, less is known about how women at high clinical or familial risk form and modify their intentions regarding risk-reducing surgery. This gap is particularly relevant for those without identified pathogenic variants or those evaluated prior to genetic testing. Our study addresses this gap by evaluating decision-making both before and after genetic testing in a real-world cohort of high-risk women, including those with negative or uncertain genetic results.
Materials and methods
Study population
We included women over 18 years of age followed at the High-Risk outpatient clinic of the Women’s Hospital “Prof. Dr. José Aristodemo Pinotti” – Center for Comprehensive Women’s Health Care (CAISM/UNICAMP), during the period from November 2021 to October 2022, who met the following criteria:
Asymptomatic women with a family history of breast/ovarian cancer in at least one first- or second-degree relative diagnosed before age 45, or those fulfilling NCCN version 2.2021 high-risk criteria11.
Women with a personal history of breast cancer (luminal or HER2-positive diagnosed before age 45, or triple-negative diagnosed before age 60), who also had a family history of breast, ovarian, or prostate cancer in a first- or second-degree relative, or fulfilled the NCCN high-risk criteria.
The project was approved by the State University of Campinas Research Ethics Committee’s (CAAE: 54179621.1.0000.5404.
Measurements
Recruitment occurred during routine outpatient consultations. Initially, participants completed a structured questionnaire collecting sociodemographic (age, ethnicity, marital status, educational level), baseline data (body mass index (BMI), smoking, alcohol use, comorbidities, medication use, gynecological, personal history of cancer) and family history data. Individualized breast and ovarian cancer risk were estimated using the Tyrer–Cuzick and CanRisk models. Based on these data, all participants received standardized pre-test genetic counseling, which included information on hereditary cancer syndromes, gene-specific cancer risks, benefits and limitations of genetic testing, and potential preventive strategies. After this pre-test counseling—but before disclosure of any genetic test results—participants were asked about their intention to undergo RRSO, with possible answers being: “no,” “I don’t know,” “yes,” or “not applicable” (in the case of patients who had already undergone the procedure). Subsequently, they were referred for blood collection, and the material was sent to the Eurofins Scientific Genome Center for comprehensive next-generation sequencing (NGS) of all coding regions and adjacent exon flanking regions, including copy number variations (CNV), of 139 genes related to hereditary cancer syndromes (supplementary Table 1). After sequencing, gene variants were classified according to standardized criteria into pathogenic variants (PV), likely pathogenic variants (LPV), and variants of uncertain significance (VUS), based on previously published data. Benign and likely benign variants were not reported. When the test result was available, patients were called for a new appointment in person or, when not possible, by telephone, where they received the test result and post-test genetic counseling which was delivered by trained physicians and included discussion of hereditary cancer syndromes, gene-specific cancer risks, benefits, and adverse effects of RRSO, fertility implications, menopausal symptoms, hormone replacement therapy considerations, and alternative risk-reduction strategies. After the conclusion of this counseling session, during the same encounter, participants were asked about their intention to undergo RRSO.
Statistical analysis
To describe the sample profile according to the study variables, frequency tables were created for categorical variables with absolute frequency (n) and percentage (%) values, and descriptive statistics were generated for numerical variables with values of mean, standard deviation, minimum and maximum values, median, and quartiles. The Chi-Square test or Fisher’s exact test (for expected value s less than 5) was used to compare categorical variables. The Mann-Whitney test (for 2 categories) and the Kruskal-Wallis test (for 3 or more groups) were used to compare numerical variables, due to the absence of a normal distribution of the variables. To compare the opinion between before and after the genetic test, the McNemar test was used for related samples (2 categories) and the Bowker’s symmetry test (3 or more categories). To analyze the factors associated with the change in desire regarding salpingo-oophorectomy before and after the genetic test, univariate logistic regression analyses were initially performed. Variables were selected with a stepwise selection criterion for inclusion in the multivariable model. The polytomous model, with 4 categories, was adjusted in the following order: ‘N-> N’ (1), ‘Y-> N’ (2), ‘N-> Y’ (3), and ‘Y-> Y’ (4). The level of significance adopted for the statistical tests was 5%, p < 0.05. All analyses were performed using The SAS System for Windows (Statistical Analysis System), version 9.412–16.
Statement
The authors declare that all methods were carried out in accordance with relevant guidelines and regulations. The principles stated in the Declaration of Helsinki (World Medical Association, 2013) and in Resolution 466/2012 of the National Health Council (NHC) were followed.
Results
The population included in this study was the same as that of another cohort previously published by our group, except for participants who had already undergone RRSO for any reason17, resulting in a study population of n = 355 patients. The median age of participants was 43 ± 11 years (mean ± standard deviation). Most were white (60.3%), younger than 50 years (71.5%), premenopausal (61.6%), and had a family history of cancer in first-degree relatives (61.1%). Table 1 shows the demographic characteristics of the study population stratified by pre-test intention to undergo RRSO. Pre-test intention to undergo RRSO was significantly more frequent among women aged 40–49 years, followed by those under 40, and less frequent among those aged ≥ 50 years (p = 0.017); among premenopausal compared to postmenopausal women (p < 0.001); and among women with higher education compared to those with lower educational levels (p = 0.039).
Table 1.
Clinical and demographic characteristics of the study population.
| Variables | Pre-test intention to undergo risk-reducing salpingo-oophorectomy | |||
|---|---|---|---|---|
| No | Yes | Total | p* | |
| n (%) | n (%) | n (%) | ||
| 204 (57,5) | 151 (42,5) | 355 (100) | ||
| Age (Years) | ||||
| < 40 | 64 (31,4) | 56 (37,1) | 120 (33,8) | 0,017 |
| 40–49 | 70 (34,3) | 64 (42,4) | 134 (37,7) | |
| ≥ 50 | 70 (34,3) | 31 (20,5) | 101 (28,5) | |
| Ethnicity | ||||
| White | 121 (59,3) | 93 (61,6) | 214 (60,3) | 0,665 |
| Not-white | 83 (40,7) | 58 (38,4) | 141 (39,7) | |
| Body Mass Index (BMI) | ||||
| < 20 | 11 (5,4) | 8 (5,3) | 19 (5,4) | 0,784 |
| 20–24,9 | 53 (26) | 33 (21,9) | 86 (24,2) | |
| 25-29.9 | 81 (39,7) | 67 (44,4) | 148 (41,7) | |
| ≥ 30 | 59 (28,9) | 43 (28,5) | 102 (28,7) | |
| Menopause | ||||
| Pre-menopause | 107 (53,2) | 110 (78,2) | 217 (61,6) | < 0,001 |
| Post-menopause | 94 (46,8) | 41 (27,1) | 135 (38,4) | |
| Family history of cancer in first-degree relatives | ||||
| No | 73 (35,8) | 65 (43) | 138 (38,9) | 0,165 |
| Yes | 131 (64,2) | 86 (57) | 217 (61,1) | |
| Breast cancer history in mother | ||||
| No | 131 (64,2) | 92 (60,9) | 223 (62,8) | 0,526 |
| Yes | 73 (35,8) | 59 (39,1) | 132 (37,2) | |
| Ovarian cancer history in mother | ||||
| No | 196 (96,1) | 144 (95,4) | 340 (95,8) | 0,741 |
| Yes | 8 (3,9) | 7 (4,6) | 15 (4,2) | |
| Family history of cancer in second-degree relatives | ||||
| No | 76 (37,3) | 54 (35,8) | 130 (36,6) | 0,904 |
| Yes | 126 (61,8) | 96 (63,6) | 222 (62,5) | |
| Education | ||||
| Up to elementary school | 53 (26) | 23 (15,2) | 76 (21,4) | 0,039 |
| High school | 88 (43,1) | 69 (45,7) | 157 (44,2) | |
| Higher education and postgraduate | 63 (30,9) | 59 (39,1) | 122 (34,4) | |
| Menarche (average age in years) | ||||
| Previous pregnancy | 12,7 | 12,4 | 12,5 | 0,158 |
| 160 (79,6) | 129 (85,4) | 289 (82,1) | ||
| Parity | ||||
| 0 | 42 (20,7) | 22 (14,6) | 64 (18,1) | 0,321 |
| 1–2 | 100 (49,3) | 78 (51,7) | 178 (50,3) | |
| ≥ 3 | 61 (30) | 51 (33,8) | 112 (31,6) | |
Regarding genetic testing, all 355 patients were tested, and among them, 51 (14.3%) had normal results, 202 (56.9%) presented a variant of uncertain significance (VUS), and 102 (28.7%) carried likely pathogenic or pathogenic variants (LPV/PV). The most prevalent LPV/PV genes identified in our analysis were BRCA1 (45.4%), BRCA2 (13.9%), MUTYH (7.4%), TP53 (5.5%), and PALB2 (5.5%) (Duarte et al., 2024).
When asked, 151 (42.5%) patients expressed a desire to undergo RRSO before genetic testing, and after testing and genetic counseling, this number decreased to 104 (33.4%), demonstrating the influence of test results and appropriate counseling on patients’ decisions (Table 2). Regarding to changes in surgical intention, 66 (21,2%) women reversed their initial intention and declined to undergo risk-reducing surgery after receiving genetic testing results and counseling (Yes → No), whereas 15 (16.9%) changed their initial preference and opted for surgery (No → Yes) upon learning that they carried LPV/PV in high-risk genes (Table 3).
Table 2.
Intention to undergo RRSO of all study population pre- and post-genetic testing.
| Intention to undergo RRSO | Pre-test n (%) |
Post-test n (%) |
|---|---|---|
| No/do not know | 204 (57,5) | 208 (66,1) |
| Yes | 151 (42,5) | 107 (33,9) |
| Total | 355 (100,0) | 315 (100,0) |
* McNemar test: χ² = 18.2, p < 0.001.
Table 3.
Change in behavior regarding the intention to undergo risk-reducing salpingo-oophorectomy according to genetic testing.
| Behavior change regarding risk-reducing salpingo-oophorectomy | Genetic test result (n%) | ||||
|---|---|---|---|---|---|
| Non-VUS or non-LPV/PV n (%) | VUS n (%) |
LPV/PV n (%) |
Total n (%) |
p | |
| No change | |||||
| No → No | 28 (62,2) | 94 (53,1) | 19 (21,3) | 141 (45,3) | < 0,001* |
| Yes → Yes | 9 (20,0) | 25 (14,1) | 43 (48,3) | 77 (24,8) | |
| With Change | |||||
| Yes → No | 5 (11,1) | 49 (27,7) | 12 (13,5) | 66 (21,2) | |
| No → Yes | 3 (66,7) | 9 (5,1) | 15 (16,9) | 27 (8,7) | |
| Total | 45 (100,0) | 177 (100,0) | 89 (100,0) | 311 (100,0) | |
In the multivariable logistic regression analysis evaluating predictors of change in intention toward RRSO before and after genetic testing, menopausal status remained independently associated with change in intention. Specifically, premenopausal women were more likely to maintain or adopt a positive intention toward RRSO after testing and counseling. The complete results of this model are presented in Supplementary Table S2, S3, S4 and S5.
The intention to undergo risk-reducing mastectomy after genetic testing was the variable most strongly associated with the intention to undergo RRSO, with women being nearly 40 times more likely to proceed with the procedure. In addition, an abnormal genetic test result with LPV/PV, the presence of LPV/PV in BRCA genes, and a personal history of cancer were also significantly associated with this outcome (Tables 4 and 5).
Table 4.
Results of simple logistic regression analysis for intention to undergo RRSO after genetic testing (n = 315).
| Variables | Univariate analysis | Multivariate analysis | |||
|---|---|---|---|---|---|
| Categories | Value-P | O.R* | 95% CI O.R* | Value-P O.R 95% CI O.R* | |
| Age (years) | ≥ 50 | --- | 1 | --- | ---- |
| 40–49 | 0.293 | 1.38 | 0.76–2.52 | ||
| < 40 | 0.423 | 1.28 | 0.70–2.34 | ||
| Ethnicity | White | --- | 1 | --- | ---- |
| Not-white | 0.316 | 0.78 | 0.48–1.26 | ||
| Body Mass Index (BMI) | < 20 | --- | 1 | --- | ---- |
| 20–24,9 | 0.045 | 0.35 | 0.13–0.97 | ||
| 25-29.9 | 0.134 | 0.48 | 0.18–1.26 | ||
| ≥ 30 | 0.147 | 0.48 | 0.17–1.30 | ||
| Menopause | Post-menopause | --- | 1 | --- | ---- |
| Pre-menopause | 0.177 | 1.42 | 0.85–2.38 | ||
| Personal history of cancer | No | --- | 1 | --- | ---- |
| Yes | 0.007 | 1.92 | 1.20–3.08 | ||
| Family history of cancer in first-degree relatives | No | --- | 1 | --- | ---- |
| Yes | 0.891 | 0.97 | 0.60–1.56 | ||
| Mother’s history of breast cancer | No | --- | 1 | --- | ---- |
| Yes | 0.667 | 0.85 | 0.40–1.81 | ||
| Family history of cancer in second-degree relatives | No | --- | 1 | --- | ---- |
| Yes | 0.248 | 0.75 | 0.47–1.22 | ||
| Education | Until elementary school | --- | 1 | --- | ---- |
| High school | 0.058 | 1.84 | 0.98–3.45 | ||
| Undergraduate and postgraduate | 0.972 | 1.01 | 0.52–1.98 | ||
| Previous pregnancy | No | --- | 1 | --- | ---- |
| Yes | 0.158 | 1.57 | 0.84–2.93 | ||
| Parity | 0 | --- | 1 | --- | ---- |
| 1–2 | 0.211 | 0.31 | 0.05–1.93 | ||
| ≥ 3 | 0.473 | 0.51 | 0.08–3.22 | ||
| Genetic test result | no-VUS or no-LPV/VP | --- | 1 | --- | --- 1.00 --- |
| VUS | 0.297 | 0.67 | 0.31–1.43 | 0.351 1.60 0.60–4.27 | |
| LPV/PV | < 0.001 | 5.32 | 2.42–11.73 | < 0.001 7.04 2.40–2-.66 | |
| Genetic test result (BRCA) | no-VUS or no-LPV/VP | --- | 1 | --- | ---- |
| VUS | 0.599 | 0.71 | 0.20–2.57 | ||
| LPV/PV | < 0.001 | 16.48 | 7.34–36.97 | ||
| Genetic test result (not-BRCA) | no-VUS or no-LPV/VP | --- | 1 | --- | ---- |
| VUS | < 0.001 | 0.39 | 0.22–0.67 | ||
| LPV/PV | 0.774 | 0.9 | 0.42–1.91 | ||
| Intention to undergo risk-reducing mastectomy after genetic testing | No | --- | 1 | --- | --- 1.00 --- |
| Yes | < 0.001 | 43.66 | 19.48–97.85 | < 0.001 39.05 16.80–90.79 | |
Table 5.
Results of the multivariate logistic regression analysis for the intention to undergo salpingo-oophorectomy after genetic testing (n = 286), excluding the variable ‘intention to undergo risk-reducing mastectomy after genetic testing’.
| Variables | Multivariate analysis | |||
|---|---|---|---|---|
| Categories | Value-P | O.R* | 95% CI O.R* | |
| Genetic test result (BRCA) | no-VUS or no-LPV/VP | --- | 1 | --- |
| VUS | 0.71 | 0.78 | 0.20–2.96 | |
| LPV/PV | < 0.001 | 15.46 | 6.05–39.53 | |
| Personal history of cancer | No | --- | 1 | --- |
| Yes | < 0.001 | 2.69 | 1.52–4.75 | |
*Odds ratios (OR) and 95% confidence intervals (CI) were estimated using logistic regression models. The analytic sample included 286 women with complete data (post-test intention to undergo RRSO: Yes = 91, 31.8%; No = 195, 68.2%). Multivariable analysis was performed using stepwise backward selection, retaining variables with p < 0.05. Ref.: reference category.
Discussion
In this study, we evaluated the impact of genetic testing and specialized counseling on decision-making regarding risk-reducing salpingo-oophorectomy (RRSO) among high-risk women with breast and/or ovarian cancer predisposition. To our knowledge, this is the first real-world study to assess these data in the context of a middle-income country and within a public healthcare system.
We characterized the demographic profile of high-risk patients who expressed an intention to undergo RRSO before genetic testing, a common scenario in Brazilian public health services due to the lack of coverage for germline genetic testing under the Unified Health System (SUS). These women were more frequently premenopausal, aged between 40 and 49 years, and had higher educational attainment. These findings underscore the importance of recognizing the age, hormonal, and sociocultural characteristics of patients during genetic counseling. Identifying these characteristics beforehand can help tailor individualized approaches. This is particularly important in settings where genetic testing is unavailable, as it limits objective risk stratification. In such cases, shared decision-making can then be based not only on clinical criteria but also on an understanding of each patient’s expectations, concerns, and context.
A prospective cohort study that evaluated more than 2,000 women at high risk for ovarian cancer demonstrated that patients who opted for RRSO had higher personal perceptions of cancer risk as well as greater fear of developing the disease18. Thus, part of the patients’ initial decision-making may be anchored in overestimated risk perceptions. Genetic counseling, by integrating objective test data with clinical and family history, allows alignment of expectations, reduction of anxiety, and promotes more conscious and consistent choices aligned with the real risk profile.
Another relevant finding was that 21.2% of women reversed their initial intention to undergo risk-reducing salpingo-oophorectomy (RRSO) after receiving genetic test results and counseling. This group was heterogeneous in terms of genetic risk: among those who withdrew their intention, only 13.5% carried pathogenic or likely pathogenic variants. Within this subgroup, three had pathogenic BRCA variants, while nine had variants in non-BRCA genes, each associated with substantially different lifetime ovarian cancer risks. In contrast, 16.9% of women who initially did not intend to undergo surgery decided to proceed with RRSO after learning they carried PV or LPV in high-risk genes. Collectively, these findings indicate that changes in intention after genetic testing predominantly reflected gene-specific risk stratification. This supports a nuanced interpretation, suggesting that decision-making aligned with individualized genetic risk profiles.
Furthermore, our analysis revealed a strong association between the desire to undergo risk-reducing mastectomy (RRM) and the decision to proceed with RRSO. Women who intended to have breast risk-reducing surgery were almost 40 times more likely to also choose preventive oophorectomy. This aligns with a 2020 systematic review by Park et al., which found that a personal history of mastectomy significantly influenced the desire for RRSO in 80% of included studies19. In our subanalysis, 42% of patients desired RRM after testing, while 34% desired RRSO, indicating considerable interest in undergoing both procedures. This is notable, as most prior studies report a primary preference for RRSO alone20. These intention patterns may identify a subgroup of women with stronger risk-avoidant preferences, higher perceived vulnerability, and a greater inclination toward proactive prevention. Additionally, healthcare-system factors, such as access to genetic testing, specialized counseling, and surgical services, likely play a substantial role in shaping decision-making, particularly in public health settings.
Our findings, showing greater likelihood of changing intention toward RRSO among women with altered genetic results, a personal history of cancer, and premenopausal status, are supported by recent evidence in the literature. A retrospective cohort study conducted by Hassan et al. evaluated over 3,400 carriers of BRCA1 and BRCA2 LPV/PV with a previous history of breast cancer, showing that RRSO was associated with a substantial reduction in all-cause mortality (HR 0.52) and breast cancer–specific mortality (HR 0.55), without increasing cardiovascular, ischemic, or depressive risk. Moreover, the greatest benefits were observed among women over 45 years of age and those carrying LPV/PV in BRCA26.
In our cohort, 33.4% of patients (n = 104) expressed an intention to undergo RRSO after genetic testing. As noted earlier, substantial international variability exists in RRSO uptake8. This variability is influenced by multiple factors, including differences in guideline implementation, access to genetic services, insurance coverage, availability of specialized surgical care, cultural norms, and the timing of genetic counseling. Such contextual factors can significantly affect both the formation of intention and actual surgical uptake and should be considered when interpreting intention-based outcomes across different populations.
The National Comprehensive Cancer Network (NCCN) recommends RRSO for BRCA1/2 LPV/PV carriers after completion of childbearing, between 35 and 45 years of age21. However, early surgical menopause in these women has consequences. The main complaints associated with the procedure are sexual dysfunction and menopausal symptoms, though these do not appear to affect overall quality of life22. Ongoing trials such as TUBA and TUBA-WISP II are evaluating a staged approach, early salpingectomy with delayed oophorectomy, based on the hypothesis of non-inferior oncologic safety with improved menopause-related quality of life. This alternative strategy may, however, be less appealing to high-risk populations23,24.
Interestingly, our findings indicate that premenopausal women were more likely to maintain or adopt an intention toward RRSO after testing and counseling. This contrasts with much of the existing literature, which generally reports higher RRSO uptake among postmenopausal women, likely due to fewer concerns about surgically induced menopause. Our results suggest that intention toward RRSO may be strongly shaped by contextual factors such as guideline-driven counseling, the timing of risk communication, and individual perception of vulnerability, rather than by menopausal status alone.
Finally, our analysis demonstrated that a personal history of breast or ovarian cancer was associated with a 2.7-fold greater likelihood of desiring RRSO after genetic testing, regardless of the desire for mastectomy. This finding is somewhat unexpected, as patients with a previous history of breast cancer are generally not candidates for hormone replacement therapy (HRT), which is an important option to mitigate the effects of early surgical menopause. The meta-analysis by Wei et al. (2023)22showed that RRSO is consistently associated with reduced sexual pleasure, increased discomfort, and intensification of menopausal symptoms; however, these effects were significantly mitigated in women who received HRT, although not fully returning to pre-surgery levels. Thus, the greater desire for RRSO among women with cancer may reflect the prioritization of oncologic risk reduction and cancer-related anxiety over quality of life, underscoring the importance of multidisciplinary counseling for these patients, in whom HRT is contraindicated.
Among the limitations of this study are the short-term follow-up limited to the period immediately after genetic counseling and the lack of data on the long-term performance of the surgery. Therefore, we plan to conduct a follow-up study to assess adherence to the initially expressed decisions.
Conclusions
In this cohort of high-risk women, the intention to undergo RRSO was primarily associated with three factors: the intention to undergo risk-reducing mastectomy, the presence of PV/LPV in BRCA genes, and a personal history of breast or ovarian cancer. Our findings underscore that access to germline genetic testing is essential for individualized risk stratification, enabling surgical prevention decisions to be guided by objective genetic information rather than clinical suspicion alone. In settings such as Brazil, where genetic testing is not yet routinely available through the public healthcare system (SUS), these data provide real-world evidence supporting the need for personalized counseling. Such an approach ensures that high-complexity preventive measures are adopted in a conscious, individualized manner, supported by the best available evidence.
Supplementary Information
Below is the link to the electronic supplementary material.
Author contributions
Conceptualization: Cesar Cabello dos Santos, Barbara Narciso Duarte. Data curation: Bárbara Narciso Duarte; Daniel Imbassahy de Sá Bittencourt Câmara e Silva, Thiago Gaspar, Christine Elisabete Rubio Alem; Ana Elisa Ribeiro da Silva Cabello; Sandra Regina Campos Teixeira; Ana Lídia Viaro, Cesar Cabello. Acquisition of financing: Cesar Cabello dos Santos. Investigation: Bárbara Narciso Duarte; Daniel Imbassahy de Sá Bittencourt Câmara e Silva, Thiago Gaspar, Christine Elisabete Rubio Alem; Ana Elisa Ribeiro da Silva Cabello; Sandra Regina Campos Teixeira; Ana Lídia Viaro, Cesar Cabello. Methodology: Cesar Cabello dos Santos, Ana Elisa Ribeiro da Silva Cabello. Administration: Ana Elisa Ribeiro da Silva Cabello. Features: Bárbara Narciso Duarte; Daniel Imbassahy de Sá Bittencourt Câmara e Silva, Thiago Gaspar, Christine Elisabete Rubio Alem; Ana Elisa Ribeiro da Silva Cabello; Sandra Regina Campos Teixeira; Ana Lídia Viaro, Cesar Cabello. Software: Ana Elisa Ribeiro da Silva Cabello. Supervision: Cesar Cabello dos Santos, Barbara Narciso Duarte, Ana Elisa Ribeiro da Silva Cabello. Validation: Barbara Narciso Duarte, Cesar Cabello dos Santos. View: Barbara Narciso Duarte. Writing: Barbara Narciso Duarte, Cesar Cabello dos Santos.
Funding
The project was financed by a parliamentary amendment.
Data availability
Research data are stored in an institutional repository and will be shared upon request to the corresponding author.
Declarations
Competing interests
The authors declare no competing interests.
Ethics approval
The project was approved by the State University of Campinas Research Ethics Committee’s (CAAE: 54179621.1.0000.5404).
Consent to participate
Informed consent was obtained from all individual participants included in the study.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Data Availability Statement
Research data are stored in an institutional repository and will be shared upon request to the corresponding author.