Table 1.

Summary of Interventions for Breast and Ovarian Cancer Surveillance and Risk-Reducing Surgery in BRCA Carriers

Intervention	Advantages	Disadvantages
Surveillance for breast cancer (monthly breast self-exam, semiannual clinical breast exam, annual mammogram, annual breast MRI)	Relatively noninvasive Breast MRI increases the likelihood of early-stage breast cancer detection although it is not clear that it improves survival	Breast MRI has low specificity and may lead to more diagnostic testing
Surveillance for ovarian cancer (semiannual pelvic exam, serum CA-125 and pelvic ultrasound)	Noninvasive	No evidence for efficacy of early-stage ovarian cancer detection No effect on ovarian cancer mortality Serum CA-125 has low specificity May be associated with emotional distress
RRM	Breast cancer risk reduction by 90%	Body-image issues Surgical risks: seromas, wound infection, skin flap necrosis, pain, lymphedema, shoulder dysfunction
RRSO	Ovarian cancer risk reduction by 72% Breast cancer risk reduction by 50% if completed before onset of menopause Decreases overall mortality by 60%, breast cancer mortality by 56% and ovarian cancer mortality by 79% Laparoscopic procedure	Increases risk of symptoms and health consequences of premature menopause (if performed before age 35): vasomotor symptoms, sexual dysfunction, cardiovascular disease, stroke, cognitive decline, depression, anxiety, osteoporosis, mortality Surgical risks: urinary tract injury, wound infection, pelvic abscess
RRSO+hysterectomy	As for benefits of RRSO (above) Allows for estrogen-only HT (alleviating need for progestogen) use Eliminates small risk of uterine cancer if tamoxifen is used	Surgical risks: similar to RRSO but greater risk plus vaginal cuff dehiscence, transfusion, rehospitalization, reoperation
Salpingectomy/fimbriectomy	May decrease risk of ovarian cancer May be considered as a bridge to RRSO in premenopausal women	No clear evidence of ovarian cancer risk reduction Unknown effect on breast cancer risk
Tamoxifen	Limited evidence from small studies for breast cancer risk reduction in BRCA carriers	Slightly increases risk of uterine cancer Increases risks of stroke, cataracts, thromboembolic events Side effects (vasomotor symptoms, vaginal dryness and discharge, fatigue, arthralgias)
OC	Ovarian cancer risk reduction by 50%	Concern for possible increased risk of breast cancer with prolonged use (>5 years) Increased risk of venous thromboembolic events Side effects ( nausea, bloating, breast tenderness, breakthrough bleeding)
HT after RRSO in premenopausal women	Alleviates symptoms and reduces health consequences of early menopause (cardiac disease, osteoporosis, Parkinsonism, dementia)	Side effects and risks (venous thromboembolism, stroke, breast cancer with E+P HT, cholelithiasis)

E, estrogen; HT, hormonal therapy; MRI, magnetic resonance imaging; OC, oral contraceptives; P, progestogen; RRM, risk-reducing mastectomy; RRSO, risk-reducing salpingo-oophorectomy.