Oophorectomy in Premenopausal Patients with Estrogen Receptor-Positive Breast Cancer: New Insights into Long-Term Effects

Abstract

Approximately 80% of breast cancers are estrogen receptor-positive (ER+), and 68–80% of those occur in premenopausal or perimenopausal women. Since the introduction of tamoxifen for adjuvant endocrine therapy in women with non-metastatic ER+ breast cancer, subsequent trials have demonstrated an oncologic benefit with the addition of ovarian function suppression (OFS) to adjuvant endocrine therapy. Subsequently, therapies to either suppress or ablate ovarian function may be included in the treatment plan for patients that remain premenopausal or perimenopausal after upfront or adjuvant chemotherapy and primary surgery. One strategy for OFS, bilateral salpingo-oophorectomy (BSO), has lasting implications, and the routine recommendation for this strategy warrants a critical analysis in this population. The following is a narrative review of the utility of ovarian suppression or ablation (through either bilateral oophorectomy or radiation) in the context of adjuvant endocrine therapy, including selective estrogen receptor modulators (SERMs) and aromatase inhibitors (AIs). The long-term sequelae of bilateral oophorectomy include cardiovascular and bone density morbidity along with sexual dysfunction, negatively impacting overall quality of life. As gynecologists are the providers consulted to perform bilateral oophorectomies in this population, careful consideration of each patient’s oncologic prognosis, cardiovascular risk, and psychosocial factors should be included in the preoperative assessment to assist in shared decision-making and prevent the lifelong adverse effects that may result from overtreatment.

Keywords

• bilateral salpingo-oophorectomy
• breast cancer
• ER+
• tamoxifen
• aromatase inhibitor
• endocrine therapy