Preventing Ovarian Cancer in High-risk Women: One Surgery at a Time.

Eleven genes have been identified that increase the lifetime risk of developing ovarian cancer. The cumulative cancer risk of ovarian cancer varies with the mutation type and age. Ovarian cancer risk management options include surgical risk reduction with salpingo-oophorectomy and a newer step-wise approach with interval salpingectomy and delayed oophorectomy. Women should be counseled on the pros and cons of hysterectomy in the setting of reducing the risk of other cancers; eliminating the risk of endometrial cancer in Lynch Syndrome, potential risk of serous/serous-like endometrial cancer in BRCA1 carriers, and elimination of progestogen therapy that may increase breast cancer risk.

Increasing genetic counseling referral rates through bundled interventions after ovarian cancer diagnosis.

OBJECTIVE: To increase genetic counseling referrals for patients with newly diagnosed epithelial ovarian cancer (EOC). METHODS: A practice-gap analysis was performed after measuring baseline genetic counseling referral rates to identify barriers to referral from the multidisciplinary single institution EOC care group. A Genetics Referral Toolkit consisting of a referral template, a genetic risk checklist, family history worksheet and provider and patient awareness was developed to address identified gaps with the goal of increasing referral rates. Clinical characteristics, referral placement, completion of genetic counseling/testing were abstracted for a historic cohort and intervention cohort. Data for the two cohorts were compared using chi-square, Fisher's exact test, or t-test. Association with referral was determined by univariate logistic regression. RESULTS: Eighty one patients from July through December 2013 (historic cohort) and 62 patients from July through December 2015 (intervention cohort) were identified as having a new diagnosis of EOC. Among these women, genetic counseling referral rates increased from 48.1% (39/81) in 2013 to 74.2% (46/62) in 2015 (p=0.002) after implementation of the toolkit. In a subset of patients without a previous genetic counseling referral, 87.9% (29/33) completed counseling and 79.3% (23/29) pursued testing from the historic cohort. In the intervention cohort, 60% (24/40) were seen for counseling and 100% (24/24) had testing. CONCLUSION: Application of a quality improvement process to create a Genetics Referral Toolkit increased the genetic counseling referral rate in patients with a new diagnosis of EOC. The majority of patients who were referred completed genetics consultation and elected genetic testing.

Options in Prophylactic Surgery to Prevent Ovarian Cancer in High-Risk Women: How New Hypotheses of Fallopian Tube Origin Influence Recommendations.

OPINION STATEMENT: In women at increased risk of developing ovarian cancer, risk-reducing salpingo-oophorectomy is the only intervention that has been shown to decrease mortality from ovarian cancer and is the standard of care for risk reduction. Prophylactic salpingectomy with delayed oophorectomy should be considered in high-risk premenopausal women in the setting of a clinical trial.

Localized provoked vestibulodynia: outcomes after modified vestibulectomy.

OBJECTIVE: To describe and estimate both short-term and long-term effectiveness of a large cohort of women treated with modified vestibulectomy in a single surgical service. STUDY DESIGN: A total of 202 patients who were treated with modified vestibulectomy for localized provoked vestibulodynia at Mayo Clinic in Rochester, Minnesota, were mailed a questionnaire to document severity of vulvar pain or discomfort before and after the surgery. RESULTS: In total, 115 patients returned the questionnaire. Of the 71 patients who before surgery reported pain when inserting a tampon, 52 reported attempting to insert a tampon after surgery. Of these 52 patients, 47 (90.4%) noticed moderate to substantial improvement. Pain with sexual intercourse occurred in 97.3% (107/ 110) of patients before surgery. After surgery, 90 (84.1%) of those 107 patients noted moderate to substantial improvement in their pain with intercourse. CONCLUSION: Modified vestibulectomy was a successful treatment for patients with localized provoked vestibulodynia and resulted in strong patient satisfaction, long-term effectiveness, minimal scarring, and few postoperative complications.

Extended antibiotic prophylaxis for prevention of surgical-site infections in morbidly obese women who undergo combined hysterectomy and medically indicated panniculectomy: a cohort study.

OBJECTIVE: The purpose of this study was to compare surgical-site infection rates in obese women who had extended prophylactic antibiotic (EPA) vs standard prophylactic antibiotic. STUDY DESIGN: An electronic records-linkage system identified 145 obese women (body mass index, >30 kg/m(2)) who underwent combined hysterectomy and panniculectomy from January 1, 2005, through December 31, 2008. The EPA cohort received standard antibiotics (cefazolin, 2 g) and continued oral antibiotic (ciprofloxacin) until removal of drains. Regression models were used to adjust for known confounders. RESULTS: The mean age was 56.0 + or - 12.1 years, and mean body mass index was 42.6 + or - 8.4 kg/m(2) (range, 30-86.4 kg/m(2)). The EPA cohort experienced fewer surgical-site infections (6 [5.9%] vs 12 [27.9%]; P < .001; adjusted odds ratio, 0.16; 95% confidence interval, 0.04-0.51; P < .001), had lower probability of incision and drainage (3 [2.9%] vs 5 [11.6%]; P = .05), and required fewer infection-related admissions (5 [4.9%] vs 6 [13.9%]; P = .08). CONCLUSION: Extended antibiotic prophylaxis can reduce surgical-site infections in obese women after combined hysterectomy and panniculectomy.

Challenging and complex decisions in the management of the BRCA mutation carrier.

Women afflicted by the hereditary breast and ovarian cancer syndrome face complex decisions regarding medical interventions aimed at reducing their risk of ovarian and breast cancer, interventions which in turn may interfere with their fertility and cause early menopause. This review addresses selected topics of importance and controversy in the management of the BRCA mutation carrier, such as psychological well-being and quality of life, breast and ovarian cancer screening, risk-reducing interventions for breast cancer and ovarian cancer, the issue of hysterectomy at the time of the risk-reducing salpingo-oophorectomy, health consequences of early surgical menopause, and safety of hormonal therapy after oophorectomy. The information presented is based on an extensive review of the literature on the selected topics and on the expertise of our multidisciplinary team.