health value of retaining your ovaries--Lani (plagued by computer problems,can'tlogin

Women Who Keep Ovaries Live Longer
[The New York Times; Subscribe]
Each year, hundreds of thousands of women who undergo hysterectomies have their ovaries removed along with their uterus, a practice meant to protect them from ovarian cancer. But a new study has found that women who keep their ovaries live longer.
While women who had their ovaries removed developed fewer breast cancers and almost entirely eliminated their risk of ovarian cancer over 24 years of follow-up, they were more likely to develop heart disease than women who kept their ovaries, and they were more likely to die.
The new findings — from an analysis of data in the famous Nurses' Health Study, published in the May issue of the journal Obstetrics & Gynecology — raises questions about a widespread practice. Some 300,000 American women a year, about half of those who have hysterectomies, have their ovaries removed.
"This finding is contrary to 35 years of teaching in gynecology," said the lead author, Dr. William H. Parker of the John Wayne Cancer Institute in Santa Monica, Calif.
"In the 1970s, it was decided that taking out the ovaries to prevent ovarian cancer would be the new strategy," he said. "This study shows that you're more likely to die if you have your ovaries taken out, unless you're among a group of women with a family history that places you at high risk for ovarian cancer or breast cancer."
While ovarian cancer is difficult to detect and often deadly, it is also rare, Dr. Parker explained, noting that only 34 of the study participants who kept their ovaries died of ovarian cancer during the follow-up period. "Heart disease kills more than 20 times the number of women every year," he said.
The study analyzed data on 29,380 women who had participated in the Harvard Nurses' Health Study: 16,345 who had hysterectomy with both ovaries removed, and 13,035 who had hysterectomy but kept their ovaries.
After 24 years of follow-up, women in the first group had 895 cases of breast cancer — a 25 percent lower risk than those who kept their ovaries — and 96 percent less risk of ovarian cancer (just 5 cases). But they were 12 percent more likely to die during the follow-up period. Their risk of heart disease was 17 percent higher than the risk faced by women with ovaries. They also had a 17 percent greater risk of dying of cancer. And in an unexpected finding, they were at greater risk for lung cancer.
The risks of heart disease and death appeared to be even greater for women who had their uterus and ovaries removed before age 50 and did not take estrogen, compared with women who had a hysterectomy before 50 but kept their ovaries.
The study may add to the debate over estrogen and the role it plays in heart disease in women. Dr. Parker and other experts suggested that women who kept their ovaries lived longer because even though the ovaries make less estrogen after menopause, they produce androstenedione and testosterone, which are converted into estrogen by fat and muscle.
OPEN ACCESS: Ovarian Conservation at the Time of Hysterectomy and Long-Term Health Outcomes in the Nurses' Health Study
[Obstetrics & Gynecology]
Objective: To report long-term health outcomes and mortality after oophorectomy or ovarian conservation.
Methods: We conducted a prospective, observational study of 29,380 women participants of the Nurses' Health Study who had a hysterectomy for benign disease; 16,345 (55.6%) had hysterectomy with bilateral oophorectomy, and 13,035 (44.4%) had hysterectomy with ovarian conservation. We evaluated incident events or death due to coronary heart disease (CHD), stroke, breast cancer, ovarian cancer, lung cancer, colorectal cancer, total cancers, hip fracture, pulmonary embolus, and death from all causes.
Results: Over 24 years of follow-up, for women with hysterectomy and bilateral oophorectomy compared with ovarian conservation, the multivariable hazard ratios (HRs) were 1.12 (95% confidence interval [CI] 1.03-1.21) for total mortality, 1.17 (95% CI 1.02-1.35) for fatal plus nonfatal CHD, and 1.14 (95% CI 0.98-1.33) for stroke. Although the risks of breast (HR 0.75, 95% CI 0.68-0.84), ovarian (HR 0.04, 95% CI 0.01-0.09, number needed to treat=220), and total cancers (HR 0.90, 95% CI 0.84-0.96) decreased after oophorectomy, lung cancer incidence (HR=1.26, 95% CI 1.02-1.56, number needed to harm=190), and total cancer mortality (HR=1.17, 95% CI 1.04-1.32) increased. For those never having used estrogen therapy, bilateral oophorectomy before age 50 years was associated with an increased risk of all-cause mortality, CHD, and stroke. With an approximate 35-year life span after surgery, one additional death would be expected for every nine oophorectomies performed.
Conclusion: Compared with ovarian conservation, bilateral oophorectomy at the time of hysterectomy for benign disease is associated with a decreased risk of breast and ovarian cancer but an increased risk of all-cause mortality, fatal and nonfatal coronary heart disease, and lung cancer. In no analysis or age group was oophorectomy associated with increased survival.

[TSund]

Now someone needs to do the stats with women who have had breast cancer.

[Diane H]

Super interesting study Lani, Thanks.

[harrie]

I had a oophorectomy. No one in my family has had ovarian cancer, but I do carry the BRCA2 gene which gives me an increased risk for ovarian cancer.

[Cannon]

Ditto on Terri's comment - this does not apply to women who already were dx with bc and therefore had their ovaries removed.

[AlaskaAngel]

Again, the question is: Does the blanket use of chemotherapy for early stage breast cancer patients whose ovarian function is annihilated by chemotherapy actually result in more of them them living longer than those who don't get chemotherapy, or not?

Especially considering that more often than not, the chemotherapy chosen doesn't do much of anything to their particular brand of cancer?

Since HR+'s get less benefit from chemo, is it actually cutting their lifespan shorter to do the chemo?

AlaskaAngel

[TSund]

Alaska,

Are you suggesting that the chemopause aspect of chemo is its main benefit and perhaps not warranted by overall statistics? Would the main recourse then be an estrogen decreasing RX ?

Or are you questioning the fact that chemo could well put one into permanent menopause? Do you think it's more comparable to removing the ovaries outright than to a woman going into "natural" menopause?

There's got to be some function leftover in a natural menopause that's protective...

[Lani]

noone has looked much into it as there is not drug company money to pay for grants to do so.

[Lien]

I've been on Zoladex for 4,5 years now. Have been hesitant about an ooph because I was worried about the effect. There just didn't seem to be enough info on long term effects. I was 44 at diagnosis and preferred the reversible option. It's very hard to decide which way is best. I'm looking forward to more research results on this topic.

Jacqueline

[AlaskaAngel]

Hi Terry,

Most people think losing hair or being sick is the hard part about chemotherapy. Bad as those things are, the invisible things may be a lot worse than we know. Medical therapy is so fragmented that I'm questioning what the net effect of chemotherapy for early stage bc really is. I very much believe that it is important to put endocrinologists at the center of the decision-making process, rather than leaving them out entirely at that time. Tumor boards are made up of those who know about surgery and radiation and chemotherapy but there is no authority on board at such a crucial time to connect the breasts (endocrine glands) with the rest of the body, which is what endocrinologists should be helping to do for breast cancer patients. At time of diagnosis it is hard to evaluate all the pieces of the picture in the rush to do everything possible to avoid recurrence. But consider some of the pieces that oncologists and PCPs don't discuss with patients, including:

whether the effects of chemo on the ovaries shorten actual lifespan through the loss of ovarian function

the concurrent use of steroids with chemotherapy that more often than not, result in added weight gain that then is much more difficult to lose due to menopause -- given that treatment makes it difficult to keep muscle tone, and the loss of the ability to produce as much testosterone makes it more difficult to rebuild muscle, as well as the steroid effect of muscle breakdown -- and the studies that are indicating that added weight is a risk factor -- another shortening of lifespan for so many that comes with chemotherapy, and that wouldn't be so prevalent without having that treatment.

the concurrent use of blood stimulating drugs in support of intensive chemotherapies -- another shortening of lifespan due to having chemotherapy...

Add to that the issues that are usually discussed, such as the cardiotoxic effects of some cancer regimens...

And the small percentage who will get leukemia...

I just wonder what the actual net effect is considering all the pieces, and whether those wtih early stage bc who are treated with chemotherapy actually have a shorter lifespan because they chose to have it.

[R.B.]

Thanks for posting this Lani.

Alska Angel you make some important and valid points. A lack of examination of wider implications is an inevitable consequence of a system that depends on products that are financially successful, rather than the optimal solution. There is no financial incentive to drive full examination of no treatment options - it is the inevitable consequence of human behaviour in a financial market. Sometimes treatment will be a better option, and sometimes not, but the current way we do things may not give us the most accurate answers.

I saw suggestions some of which I posted that a primary route of action of some chemos was by ovarian ablation. Papers suggested if the ovaries were not ablated the chemo was less effective.

The reproductive system and hormones are a massively complex topic.

A book called The Reproductive System at a Glance
By Linda J. Heffner, Danny J. Schust states "in obese women, conversion of androgens to oestrone in adipose tissue can be a major source of excessive amounts of circulating oestrogen"

So many questions.

[Hopeful]

AA,

To your list of possibilities not considered I would add that chemotherapy may cause less virulent cancers to mutate into more aggressive ones by continually challenging them and then giving them enough time to recover between treatments. A very similar effect can be seen with antibiotics, which, due to overuse, have now turned ordinary viruses into superbugs that are antibiotic resistant. As you have pointed out, adriamycin, a very widely used chemotherapy in early bc, is an antibiotic. Food for thought.

R.B.,

I think you have hit the nail on the head. Oncologists' and pharmaceutical manufacturers' livelihoods depend on treating as many patients as possible with as many of these drugs as possible. Cynical as it may sound, we need to not lose sight of the fact that bc treatment is a billion dollar industry in the USA. I think this is a big impediment to finding alternative treatments, and the reason why any new drug is automatically combined with chemo in a trial, to see if it can make the chemo work better, rather than determine if it can replace chemo with something less toxic and potentially more effective.

Hopeful