Recommendation 6

• Bilateral salpingectomy alone for ovarian/tubal/peritoneal cancer risk reduction in women who harbour a pathogenic or likely pathogenic variant in BRCA1 and BRCA2 is still under investigation and should only be offered as an alternative to RRSO under a research protocol or if RRSO is an unacceptable choice for the patient.

• Bilateral salpingectomy is an option for women who harbour a pathogenic or likely pathogenic variant in BRCA1 and BRCA2 who are younger than the recommended age for RRSO and do not wish to conceive further pregnancies (without assisted reproductive technologies).

• The inclusion of hysterectomy with RRSO for harbour a pathogenic or likely pathogenic variant in BRCA1 and BRCA2 should be individualized, taking into account risk factors for uterine cancer, other uterine pathology, and tamoxifen use.

• There are insufficient data to routinely recommend hysterectomy to reduce the risk of papillary serous uterine cancer in women who harbour a pathogenic or likely pathogenic variant in BRCA1.

This is endorsed from Jacobson et al. 2018 [23]

Qualifying Statements for Recommendation 6

• A 2016 Dutch study examined mathematical models for ovarian cancer risk following two-step surgery in women who harbour a pathogenic or likely pathogenic variant in BRCA1 and BRCA2. The investigators determined that whether salpingectomy offers (at its worst) a 35% risk reduction in ovarian cancer or (at its best) performs at the level of RRSO, an interval salpingectomy followed by bilateral oophorectomy five years later within the recommended window for preventive surgery affords risk reduction similar to that with RRSO alone [31].

Key Evidence for Recommendation 6

We endorse the recommendations from the clinical practice guideline conducted by Jacobson et al. [23] on behalf of the SOGC. This guideline scored well on the AGREE II scale. The scores are reported in Table 4–3 in Section 4 of this document. The evidence underpinning the recommendations is primarily comprised of a guideline from 2017 and comparative studies.

Justification for Recommendation 6

The Working Group members are confident in their endorsement of this recommendation. The source had adequate quality ratings, there is an excellent alignment with research questions of interest to the Working Group, methods and evidence and synthesis are convincing, and the treatments and patients included in the evidence base are generalizable to the Ontario context.