Johns Hopkins Gynecologic Oncology - Gynecologic Cancer Risk for Breast Cancer Survivors

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The Department of Gynecology and Obstetrics
The Kelly Gynecologic Oncology Service

The Risk of Developing Gynecologic Cancer for Survivors of Breast Cancer

Topics:

Introduction
Ovarian Cancer
Endometrial Cancer
Summary
References

Introduction: Fortunately, the majority of women who develop breast cancer will survive this disease. However, for numerous reasons, these women are at an increased risk of developing one or the other of the two most common gynecologic malignancies: ovarian epithelial or endometrial cancer. In this concise overview we will summarize the present state of knowledge regarding these increased risks and the issues of appropriate screening.

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Ovarian Cancer: Women who develop breast cancer are at an increased risk of developing ovarian cancer. This increase in the probability of developing ovarian cancer is a result of both the genetic pre-dispositions that may have lead to the development of breast cancer and the lifestyle choices and unique individual risks¹ . In general, women who have had breast cancer have a doubling of their chance of developing ovarian cancer, an increase in a life time risk of from 1 in 70 to about 1 in 35. There are subgroups of women who have much higher risks of developing post breast cancer ovarian cancer, with lifetime risks that may approach 50%. These women all have strong family histories with many of them having documented genetic abnormalities such as BRCA 1 or 2. It is important for a woman to have an understanding as to what her risk is of developing ovarian cancer after she has had breast cancer. We strongly encourage our patients to undergo a formal risk assessment, such as that which is available at the Johns Hopkins Breast and Ovarian Surveillance Service (BOSS). Based upon a woman's individual risk of developing ovarian cancer, it may be appropriate to institute a focussed screening regimen (serial history and physical examinations with vaginal probe ultrasounds evaluating ovarian architecture, volume, and blood flow² ) or even perform a prophylactic oophorectomy. The standards as to who should be screened or undergo a prophylactic oophorectomy are not universal and must take into consideration a myriad of patient related variables. Open discussion between a woman and her health care provider is essential.

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Endometrial cancer: Endometrial cancer is the most common gynecologic malignancy effecting American women. Fortunately, because this disease is usually diagnosed early and easily treated, relatively few women die as a consequence of developing endometrial cancer. Women who have had breast cancer have, in general, a doubling of their life time risk of developing endometrial cancer (1 in 50 to 1 in 25). Additionally, those women who are treated with tamoxifen have as much as a further doubling in their chance of developing endometrial cancer³ . This additive increase in risk is related to the length of time that tamoxifen is taken. A few years after having stopped tamoxifen, the woman's individual risk returns to that of the general population of breast cancer survivors. We do not recommend that women with breast cancer undergo any specific endometrial cancer screening studies, as these investigations have not been proven to be either meritorious or cost effective. However, we strongly encourage our patients to be alert for any of the symptoms of endometrial cancer, the most common of which is new or abnormal vaginal bleeding. If these symptoms occur, the patient should return to see her health care professional as soon as possible so that appropriate evaluation can be initiated.

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Summary: A small, though important, percentage of women with breast cancer will develop a second gynecologic malignancy. With patient awareness and, when appropriate, screening and intervention, few of these women will have a negative out come as a result of a gynecologic cancer.

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References:

¹ Antoniou AC, Gayther SA, Stratton JF, Ponder B, Easton DF. Risk models for familial ovarian and breast cancer. Genet Epidemiol 2000; 18:173-190.
² Jacobs IJ, Skates SJ, MacDonald N, et al. Screening for ovarian cancer: a pilot randomised control trial. Lancet 1999; 353:1207-1210.
³ Rutqvist LE, Johansson H, Signomklao T, et al. Adjuvant tamoxifen therapy for early stage breast cancer and second primary malignancies. J Natl Cancer Inst 1995;87:645-652.

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