Treatment Injury

Surgery to prevent risk of ovarian cancer

Anne, a 57-year-old, underwent elective prophylactic bilateral oophorectomy to remove both ovaries, as prophylaxis against ovarian cancer.

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Event: Surgery to prevent risk of ovarian cancer.
Injury: Unnecessary surgery.

Key points

  • Pre-menopausal bilateral oophorectomy is recognised as a common practice for surgical prophylaxis against the recurrence of oestrogen-dependent breast cancer
  • In someone deemed to be at high risk for the occurrence of ovarian cancer, bilateral oophorectomy is considered a sub-optimal prophylaxis
  • To prevent the occurrence of ovarian cancer, bilateral salpingo-oophorectomy is recommended
  • Routine consent should include informing the patient of the technical nature of the procedure, its role in risk reduction and any long-term side-effects
  • Pre-menopausal patients should be informed of options for managing menopausal symptoms and other long-term side-effects post risk-reducing surgery, including the use of hormone replacement therapy.

Case Study

Anne, a 57-year-old, underwent elective prophylactic bilateral oophorectomy to remove both ovaries, as prophylaxis against ovarian cancer.

Anne had a history of two episodes of pre-menopausal breast cancer and ductal carcinoma in situ (DCIS). In view of this history, Anne and her daughters had seen the medical geneticist.

A breast cancer susceptibility gene (BRCA) analysis was done but it did not identify any gene mutations. However, the geneticist advised Anne that, given her history, she had an increased risk of ovarian cancer.

Anne was referred to a gynaecological oncologist to discuss prophylactic treatment against ovarian cancer and was advised that she should consider elective prophylactic bilateral oophorectomy.

After meeting the gynaecological oncologist, Anne chose to undergo an elective prophylactic bilateral oophorectomy, and four months later underwent uncomplicated surgery and was discharged home the next day. A sample sent for histology showed no evidence of abnormal cells or malignancy.

About two weeks after surgery, Anne’s case was discussed at a multidisciplinary meeting that included the oncologists, surgeons and pathologists. At the meeting it was agreed that, rather than the bilateral oophorectomy that she had already had, bilateral salpingo-oophorectomy was recommended as a standard technical procedure for surgery to prevent the risk of ovarian cancer. This was also noted in the histology report.

The new recommendation was discussed with Anne and her husband during her follow-up visit. Anne agreed for her name to be placed on the waiting list for bilateral salpingectomy to remove her fallopian tubes, and surgery was performed. The histology of the samples from this surgery also showed no adverse pathology.

In discussion with her surgeon Anne lodged a treatment injury claim for unnecessary surgery, as she had undergone two operative procedures when one would have sufficed. ACC sought a report from the surgeon and external clinical advice from a gynaecologist. Whilst the decision to remove the ovaries was reasonable, more recent knowledge recommends a bilateral salpingo-oophorectomy to prevent the risk of ovarian cancer.

After assessing the information, ACC accepted the claim and was able to assist Anne with her treatment costs and temporary loss of income while she recovered from the surgery.

Commentary

Dr Sylvia K Rosevear BA MB ChB, MD, FRCOG, FRANZCOG

This case is interesting because there were no clinical complications either intra-operatively or subsequently. The patient had been referred by the clinical geneticist who had discussed with her the degree of risk for ovarian cancer given her early-onset breast cancer at the age of 25 and subsequent DCIS at age 38. She wished to have a procedure that reduced that risk even though there was no BRCA1 and BRCA2 mutation identified. In retrospect, it was acknowledged that a less-than-optimal surgical procedure had been performed for risk prophylaxis for the occurrence of ovarian cancer in someone deemed to be high risk.

Despite being seen by two consultant gynaecologists and a registrar, bilateral oophorectomy was performed. Common practice is for bilateral oophorectomy to be done pre-menopausally as surgical prophylaxis for the recurrence of breast cancer as an oestrogen-dependent tumour. The standard technical procedure for prophylaxis for ovarian cancer is a salpingo-oophorectomy because it is now considered that ovarian epithelial cancer is of extra-ovarian origin1-5. It arises in the ampullary section of the tube. This was raised by the pathologist at the clinic-pathological departmental meeting subsequent to her initial surgery. It was corrected with the patient undergoing a further laparoscopic procedure for removal of the tubes.

The need for salpingo-oophorectomy represents a paradigm shift in understanding of which gynaecological oncologists have been aware for about three years, but it may not be part of general gynaecological understanding. It illustrates the necessity to be familiar with accessing guidelines in specialty areas. These need to be up to date. For instance, recommendations for the management of women at high risk of ovarian cancer are well documented in a clinical practice guideline developed by the Australian National Breast and Ovarian Cancer Centre.

The gynaecologist, in addition to informing the patient of the technical nature of the procedure and confirming the intentions of the surgery for risk reduction6, in terms of informed consent should discuss the issues of the management of menopausal symptoms (should the woman be pre-menopausal) and other long-term side-effects post risk-reducing surgery, including the use of hormone replacement therapy. Other issues are factors influencing psychosocial wellbeing post risk-reducing salpingo-oophorectomy (RRSO). The evidence for the benefit of RRSO is level 3 (cohort studies)7. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) statement on prophylactic oophorectomy is due for review in July 2012. It is useful for the consideration of ancillary issues associated with the removal of tubes and ovaries8.

References

  1. http://guidelines.nbocc.org.au/guidelines/high-risk-ovarian/ch0s11.php.
  2. Crum CP, Drapkin R, Kindelberger DW, Medeiros F, Miron A, Lee Y. Lessons from BRCA: The tubal fimbria emerges as an origin for pelvic serous cancer. Clin Med Res. 2007 5 (1):35-44.
  3. Kurman RJ, Shih IM. Pathogenesis of ovarian cancer: lessons from morphology and molecular biology and their clinical implications. International Journal Gynaecology Pathology 2008 27 (2):151-60.
  4. Kurman RJ, Shih IM. Molecular pathogenesis and extraovarian origin of epithelial ovarian cancer – shifting the paradigm. Human Pathology 2011 42 (7):918-31.
  5. Kuhn, E, Kurman RH, Shih IM. Ovarian cancer is an imported disease: Fact or Fiction? Curr Obstet Gynecol Rep. 2012 Mar; 1(1):1-9.
  6. Rebbeck TR, Kauff ND, Domchek SM. Meta-analysis of risk reduction estimates associated with risk-reducing salpingo-oophorectomy in BRACA1 or BRCA2 mutation carriers. J Natl Cancer Inst. 2009 Jan 21;101(2):80-7.
  7. National Health and Medical Research Council. NHMRC additional levels of evidence and grades for recommendations for developers of guidelines. Canberra: Commonwealth of Australia; 2009.
  8. RANZCOG College Statement C-Gyn 25. Prophylactic oophorectomy at the time of Hysterectomy for Benign Conditions (C-GYn 25).

Claims Information

Between 1 July 2005 and 15 June 2012, ACC received 13 claims for unnecessary surgery relating to bilateral oophorectomies and salpingo-oophorectomies.

Of the 13 claims lodged, eight were accepted and five were declined. The most common reason for declining was that the surgery was a necessary part of treatment.

About this case study

This case study is based on information amalgamated from a number of claims. The name given to the patient is therefore not a real one. The case studies are produced by ACC’s Treatment Injury Centre, to provide health professionals with:

  • an overview of the factors leading to treatment injury
  • expert commentary on how similar injuries might be avoided inthe future.

The case studies are not intended as a guide to treatment injury cover. Send your feedback to: TI.info@acc.co.nz

How ACC can help your patients following treatment injury

Many patients may not require assistance following their treatment injury. However, for those who need help and have an accepted ACC claim, a range of assistance is available, depending on the specific nature of the injury and the person’s circumstances. Help may include things like:

  • contributions towards treatment costs
  • weekly compensation for lost income (if there’s an inability to work because of the injury)
  • help at home, with things like housekeeping and childcare.

No help can be given until a claim is accepted, so it’s important to lodge a claim for a treatment injury as soon as possible after the incident, with relevant clinical information attached. This will ensure ACC is able to investigate, make a decision and, if covered, help your patient with their recovery.

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Published 01/10/2012

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