Prophylactic surgery

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Prophylactic surgery
Other namesPreventive surgery

Prophylactic surgery (also known as preventive surgery or risk-reducing surgery), is a form of surgery whose purpose is to minimize or prevent the risk of developing cancer in an organ or gland that has yet to develop cancer and is known to be at high risk of developing cancer. [1] [2] [3] This form of preventive healthcare may include surgeries such as mastectomies, oophorectomies, colectomies and surgical corrections, such as the surgical correction of cryptorchidism or undescended testis. [4] Another less common definition of prophylactic surgery also includes the prevention of other diseases, outcomes or future appearance. [5] [6]

Contents

History

Throughout most of history, preventive medical techniques have been largely ignored and mostly only relegated to scarce occurrences. Despite the prevalence of diseases such as syphilis, leprosy and the black plague throughout the late Middle Ages, the concepts of preventive medicine was largely ignored despite advancements in quarantining and sanitary techniques. [7] Furthermore, the high mortality rate of surgeries both during and post-operation deemed these procedures to be too high of a risk to take for a preventive measure. [8] This changed however with the introduction of anesthesia, advancements in anatomy and with the introduction anti-septic or aseptic techniques alongside further advancements in sanitary techniques in the 19th to 20th century allowed surgeons to consider prophylactic surgeries without running the high risks previously experienced. [9]

Patient considerations

One may choose to undergo prophylactic surgery if they believe that it is within their best interest to undergo a procedure in order to remove a high-risk organ or gland. There are several types of preventable surgeries that are known to substantially decrease the risk of future disease. Since prophylactic surgeries are usually permanent and irreversible, the pros and cons must be carefully weighed by individuals considering the procedure. There are a myriad of ethical, physiological and psychological considerations to be made before taking such a procedure. There are both physical and mental implications that come with committing to a prophylactic surgery, usually alongside the initial disadvantages that are associated with any procedure such as cost, time lost, recovery and more, there are other reasons for opting out of an operation. Ethical and religious reasons are commonly considered especially when in regards to the reproductive system and its function. Concerns about sexual and reproductive function and self-image are rather common on clear external surgeries or sexual/ reproductive related surgeries. [10] Furthermore, depending on the surgery, there may be certain unknown or unique risks attached depending on the cancer or surgical area. Additionally, undertaking a prophylactic surgery does not guarantee that the patient will never develop cancer later. [11] Ultimately, it is a very complex and personal question when it comes to making the decision on whether to operate. Individuals whom do request prophylactic surgeries can be under the influence of anxiety, uncertainty and irrational fear as a result of a test or hereditary disease may incite these fears in the individual. It is important to consider the person's own opinion, as well as those of their families and surgeon's first before committing to a prophylactic surgery. [4]

Prophylactic interventions in children

Prophylactic surgery in children has largely been justified through two grounds, the best interest of the child and public health. Since children are unlikely to be able to provide a meaningfully informed consent, it is an ethical subject discussed and heavily contested by various bioethics committees and the general public. [6]

Primary, secondary and tertiary prevention

Depending on the situation, the type of prophylactic surgery performed may be relegated to match with relevant primary, secondary or tertiary preventive measures. A primary prevention's goal is to prevent a disease or injury before it has occurred, secondary prevention's goal is to minimize the effects of an illness after it has occurred and tertiary prevention aims to manage the effects of an illness in the long term. [12] Depending on the stage of the illness or whether the patient has had an illness a different type of procedure may be required. If a cancer has not appeared already then a preventive surgery including the considerations of issues associated with metastatic breast cancer will not be considered, instead operations that conserve tissue can be discussed without considerations in case of metastasis and the patient may choose, under the context of breast cancer, may undergo a skin sparing or nipple sparing mastectomy instead of a total mastectomy. [13]

Types of prophylactic surgery

Mastectomies, especially under the context of cancer, is the most well-known form of prophylactic surgery, however there are still a multitude of other forms of surgery used to prevent other diseases. Prophylactic surgery is not only restricted to the prevention of cancer but can also include surgery whose intended purpose is to prevent any disease or unwanted consequence surgically. [5] These can include prophylactic appendectomy, circumcision and even cosmetic surgeries as forms of prophylactic surgery. However, the terms usage is largely associated and most commonly interpreted as the prevention of cancer surgically. [11] [3] There are several examples and types of prophylactic surgery, for both cancer related and cancer unrelated diseases. In cancer related prophylactic surgeries, most individuals required to do these surgeries have either already been effected by a related cancer or have an inherited cancer. These hereditary cancer syndromes contribute to 5-10 percent of all cancers. [14]

Cancer

Prophylactic mastectomy

Prophylactic mastectomy is the surgical removal of breast tissue to remove cells that are at risk of developing cancer. These are most commonly done in women whom have BRCA1 or BRCA2 mutations discovered from gene testing, have already had cancer in one breast, have a family history of breast cancer or have undergone radiation therapy to their chest increasing their risk of developing breast cancer. Instances of post-surgery complications are common with two-thirds of women experiencing at least one complication post-surgery. However, women whom have opted for simultaneous reconstruction after surgery have shown a slightly significant lower risk of complication at 64%. [15]

Prophylactic salpingectomy

Prophylactic salpingectomy is the surgical removal of the Fallopian tube which when done as a preventive measure, may be done to prevent pregnancies as a form of contraception, or as a method to prevent cancer. Women who underwent prophylactic salpingectomy have shown to have a lower incidence of ovarian cancer compared to women who have not undergone the procedure from 2.2% to 13% and from 4.75% to 24.4%. Furthermore, it has been shown that salpingectomy may reduce 29.2% to up to 64% of ovarian cancer incidence.[ spelling? ] For most women, it has been shown to have no significant effect on ovarian function, quality of life, sexuality, and its cost-effective profile. [16]

Prophylactic oophorectomy

Prophylactic oophorectomy is the removal of the ovaries and is either done as a planned response to the genetic risk of ovarian or breast cancer, especially among women whom have a hereditary family history of ovarian cancer, have the BRCA1 or BRCA2 mutations, [17] or have developed breast cancer in the past. [18] Oophorectomy when done alongside salpingectomy as a bilateral salpingo-oophorectomy, [17] or alongside hysterectomy or all together, have shown to significant decrease instances of ovarian cancer if the individual has a known history of BRCA1 or BRCA2 mutations and if they have an identified genetic risk of breast and ovarian cancer. However, hormone replacement therapy and less invasive methods of treating menorrhagia and fibroids have become more common, making prophylactic oophorectomy a less common choice in unaffected women without a hereditary history of breast or ovarian cancer. [19]

Prophylactic Colectomy

Prophylactic Colectomy is the removal of part or all of the colon in an effort to prevent cancer in the colon. [20] This is especially prevalent in individuals with hereditary colorectal cancer syndromes like hereditary non-polyposis colorectal cancer [4] or familial adenomatous polyposis. [21] Individuals affected by these inherited cancers can carry a risk of 80% to up to nearly 100% in some cases within their lifetime. Prophylactic Colectomy have shown to greatly minimise this risk with minimal disturbance to the bowel. [22]

Non-cancer

Prophylactic appendectomy

Prophylactic appendectomy is the removal of the appendix in order to remove the chances of developing appendicitis as the leading cause of acute intra-abdominal disease in more than 50% of all cases. [23] Prophylactic Appendectomy is one of the most common preventive surgeries and is the most common emergency surgery performed in the USA. [24] The procedure is very safe when performed safely under optimal conditions with little to no adverse effects on the operated individuals. [25]

Related Research Articles

<span class="mw-page-title-main">Mastectomy</span> Surgical removal of one or both breasts

Mastectomy is the medical term for the surgical removal of one or both breasts, partially or completely. A mastectomy is usually carried out to treat breast cancer. In some cases, women believed to be at high risk of breast cancer have the operation as a preventive measure. Alternatively, some women can choose to have a wide local excision, also known as a lumpectomy, an operation in which a small volume of breast tissue containing the tumor and a surrounding margin of healthy tissue is removed to conserve the breast. Both mastectomy and lumpectomy are referred to as "local therapies" for breast cancer, targeting the area of the tumor, as opposed to systemic therapies, such as chemotherapy, hormonal therapy, or immunotherapy.

<span class="mw-page-title-main">Tubal ligation</span> Surgical clipping,removal or blocking of the fallopian tubes

Tubal ligation is a surgical procedure for female sterilization in which the fallopian tubes are permanently blocked, clipped or removed. This prevents the fertilization of eggs by sperm and thus the implantation of a fertilized egg. Tubal ligation is considered a permanent method of sterilization and birth control.

<span class="mw-page-title-main">Hysterectomy</span> Surgical removal of the uterus

Hysterectomy is the surgical removal of the uterus and cervix. Supracervical hysterectomy refers to removal of the uterus while the cervix is spared. These procedures may also involve removal of the ovaries (oophorectomy), fallopian tubes (salpingectomy), and other surrounding structures. The term “partial” or “total” hysterectomy are lay-terms that incorrectly describe the addition or omission of oophorectomy at the time of hysterectomy. These procedures are usually performed by a gynecologist. Removal of the uterus renders the patient unable to bear children and has surgical risks as well as long-term effects, so the surgery is normally recommended only when other treatment options are not available or have failed. It is the second most commonly performed gynecological surgical procedure, after cesarean section, in the United States. Nearly 68 percent were performed for conditions such as endometriosis, irregular bleeding, and uterine fibroids. It is expected that the frequency of hysterectomies for non-malignant indications will continue to fall given the development of alternative treatment options.

Oophorectomy, historically also called ovariotomy, is the surgical removal of an ovary or ovaries. The surgery is also called ovariectomy, but this term is mostly used in reference to non-human animals, e.g. the surgical removal of ovaries from laboratory animals. Removal of the ovaries of females is the biological equivalent of castration of males; the term castration is only occasionally used in the medical literature to refer to oophorectomy of women. In veterinary medicine, the removal of ovaries and uterus is called ovariohysterectomy (spaying) and is a form of sterilization.

<span class="mw-page-title-main">Ovarian cancer</span> Cancer originating in or on the ovary

Ovarian cancer is a cancerous tumor of an ovary. It may originate from the ovary itself or more commonly from communicating nearby structures such as fallopian tubes or the inner lining of the abdomen. The ovary is made up of three different cell types including epithelial cells, germ cells, and stromal cells. When these cells become abnormal, they have the ability to divide and form tumors. These cells can also invade or spread to other parts of the body. When this process begins, there may be no or only vague symptoms. Symptoms become more noticeable as the cancer progresses. These symptoms may include bloating, vaginal bleeding, pelvic pain, abdominal swelling, constipation, and loss of appetite, among others. Common areas to which the cancer may spread include the lining of the abdomen, lymph nodes, lungs, and liver.

Gender-affirming surgery for female-to-male transgender people includes a variety of surgical procedures that alter anatomical traits to provide physical traits more comfortable to the trans man's male identity and functioning.

<span class="mw-page-title-main">Salpingectomy</span> Surgical removal of fallopian tube

Salpingectomy refers to the surgical removal of a fallopian tube. This may be done to treat an ectopic pregnancy or cancer, to prevent cancer, or as a form of contraception.

<span class="mw-page-title-main">Colectomy</span> Surgical removal of all or part of the large intestine

Colectomy is the surgical removal of any extent of the colon, the longest portion of the large bowel. Colectomy may be performed for prophylactic, curative, or palliative reasons. Indications include cancer, infection, infarction, perforation, and impaired function of the colon. Colectomy may be performed open, laparoscopically, or robotically. Following removal of the bowel segment, the surgeon may restore continuity of the bowel or create a colostomy. Partial or subtotal colectomy refers to the removal of a portion of the colon, while total colectomy involves removal of the entire colon.

Gynecologic oncology is a specialized field of medicine that focuses on cancers of the female reproductive system, including ovarian cancer, uterine cancer, vaginal cancer, cervical cancer, and vulvar cancer. As specialists, they have extensive training in the diagnosis and treatment of these cancers.

<span class="mw-page-title-main">Hereditary breast–ovarian cancer syndrome</span> Medical condition

Hereditary breast–ovarian cancer syndromes (HBOC) are cancer syndromes that produce higher than normal levels of breast cancer, ovarian cancer and additional cancers in genetically related families. It accounts for 90% of the hereditary cancers. The hereditary factors may be proven or suspected to cause the pattern of breast and ovarian cancer occurrences in the family. The name HBOC may be misleading because it implies that this genetic susceptibility to cancer is mainly in women. In reality, both sexes have the same rates of gene mutations and HBOC can predispose to other cancers including prostate cancer and pancreatic cancer. For this reason, the term "King syndrome" has recently come into use. The new name references Mary-Claire King who identified the genes BRCA1 and BRCA2.

<span class="mw-page-title-main">Breast-conserving surgery</span> Surgical operation

Breast-conserving surgery refers to an operation that aims to remove breast cancer while avoiding a mastectomy. Different forms of this operation include: lumpectomy (tylectomy), wide local excision, segmental resection, and quadrantectomy. Breast-conserving surgery has been increasingly accepted as an alternative to mastectomy in specific patients, as it provides tumor removal while maintaining an acceptable cosmetic outcome. This page reviews the history of this operation, important considerations in decision making and patient selection, and the emerging field of oncoplastic breast conservation surgery.

<span class="mw-page-title-main">Male breast cancer</span> Medical condition

Male breast cancer (MBC) is a cancer in males that originates in their breasts. Males account for less than 1% of new breast cancers with about 20,000 new cases being diagnosed worldwide every year. Its incidence rates in males vs. females are, respectively, 0.4 and 66.7 per 100,000 person-years. The worldwide incidences of male as well as female breast cancers have been increasing over the last few decades. Currently, one of every 800 men are estimated to develop this cancer during their lifetimes.

<i>BRCA</i> mutation Medical condition

A BRCA mutation is a mutation in either of the BRCA1 and BRCA2 genes, which are tumour suppressor genes. Hundreds of different types of mutations in these genes have been identified, some of which have been determined to be harmful, while others have no proven impact. Harmful mutations in these genes may produce a hereditary breast–ovarian cancer syndrome in affected persons. Only 5–10% of breast cancer cases in women are attributed to BRCA1 and BRCA2 mutations, but the impact on women with the gene mutation is more profound. Women with harmful mutations in either BRCA1 or BRCA2 have a risk of breast cancer that is about five times the normal risk, and a risk of ovarian cancer that is about ten to thirty times normal. The risk of breast and ovarian cancer is higher for women with a high-risk BRCA1 mutation than with a BRCA2 mutation. Having a high-risk mutation does not guarantee that the woman will develop any type of cancer, or imply that any cancer that appears was actually caused by the mutation, rather than some other factor.

<span class="mw-page-title-main">Hereditary cancer syndrome</span> Inherited genetic condition that predisposes a person to cancer

A hereditary cancer syndrome is a genetic disorder in which inherited genetic mutations in one or more genes predispose the affected individuals to the development of cancer and may also cause early onset of these cancers. Hereditary cancer syndromes often show not only a high lifetime risk of developing cancer, but also the development of multiple independent primary tumors.

A preventive mastectomy or prophylactic mastectomy or risk-reducing mastectomy (RRM) is an elective operation to remove the breasts so that the risk of breast cancer is reduced.

<span class="mw-page-title-main">High-grade serous carcinoma</span> Medical condition

High-grade serous carcinoma (HGSC) is a type of tumour that arises from the serous epithelial layer in the abdominopelvic cavity and is mainly found in the ovary. HGSCs make up the majority of ovarian cancer cases and have the lowest survival rates. HGSC is distinct from low-grade serous carcinoma (LGSC) which arises from ovarian tissue, is less aggressive and is present in stage I ovarian cancer where tumours are localised to the ovary.

<span class="mw-page-title-main">Prophylactic salpingectomy</span> Surgical technique

Prophylactic salpingectomy is a preventative surgical technique performed on patients who are at higher risk of having ovarian cancer, such as individuals who may have pathogenic variants of the BRCA1 or BRCA2 gene. Originally salpingectomy was used in cases of ectopic pregnancies. As a preventative surgery, however, it involves the removal of the fallopian tubes. By not removing the ovaries this procedure is advantageous to individuals who are still of child bearing age. It also reduces risks such as cardiovascular disease and osteoporosis which are associated with the removal of the ovaries.

<span class="mw-page-title-main">Breast and ovarian cancer</span>

Breast and ovarian cancer does not necessarily imply that both cancers occur at the same time, but rather that getting one cancer would lead to the development of the other within a few years. Women with a history of breast cancer have a higher chance of developing ovarian cancer, vice versa.

<span class="mw-page-title-main">SEE-FIM Protocol</span> Pathology protocol to assess cancer risk

The SEE-FIM protocol is a pathology dissection protocol for Sectioning and Extensively Examining the Fimbria (SEE-FIM). This protocol is intended to provide for the optimal microscopic examination of the distal fallopian tube (fimbria) to identify either cancerous or precancerous conditions in this organ.

References

  1. ↑ "NCI Dictionary of Cancer Terms". National Cancer Institute. National Cancer Institute. 2011-02-02. Retrieved 2019-06-20.
  2. ↑ Mau, C.; Untch, M. (2017). "Prophylactic Surgery: For Whom, When and How?". Breast Care (Basel, Switzerland). 12 (6): 379–384. doi:10.1159/000485830. PMC   5803721 . PMID   29456469.
  3. 1 2 U.S. Department of Health and Human Services, National Institutes of Health. "NCI Dictionary of Cancer Terms". National Cancer Institute. Retrieved 17 May 2019.
  4. 1 2 3 Australian Government, Cancer Australia (2019). "Prophylactic surgery". EdCaN. Retrieved 17 May 2019.
  5. 1 2 C. Shiel Jr., William. "Medical Definition of Prophylactic". MedicineNet. Retrieved 17 May 2019.
  6. 1 2 Howe, R. S. Van; Svoboda, J. S.; Hodges, F. M. (1 February 2002). "Prophylactic interventions on children: balancing human rights with public health". Journal of Medical Ethics. 28 (1): 10–16. doi:10.1136/jme.28.1.10. ISSN   0306-6800. PMC   1733522 . PMID   11834752.
  7. ↑ "Preventive medicine". Encyclopedia Britannica. Retrieved 2019-05-31.
  8. ↑ Moscucci, Ornella; Clarke, Aileen (March 2007). "Prophylactic oophorectomy: a historical perspective". Journal of Epidemiology and Community Health. 61 (3): 182–184. doi:10.1136/jech.2006.046474. ISSN   0143-005X. PMC   2652903 . PMID   17325391.
  9. ↑ "History of Surgery". Hartford Stage. Retrieved 2019-05-31.
  10. ↑ "Prophylactic Mastectomy Risks". Breastcancer.org. Retrieved 2019-05-31.
  11. 1 2 U.S. Department of Health and Human Services, National Institutes of health. "Surgery as a Preventive measure". National Cancer Institute. Retrieved 17 May 2019.
  12. ↑ "Primary, secondary and tertiary prevention | Institute for Work & Health". www.iwh.on.ca. Retrieved 2019-05-31.
  13. ↑ Untch, Michael; Mau, Christine (2017). "Prophylactic Surgery: For Whom, When and How". Breast Care. 12 (6): 379–384. doi:10.1159/000485830. ISSN   1661-3791. PMC   5803721 . PMID   29456469.
  14. ↑ "Genetics". National Cancer Institute. 2015-04-22. Retrieved 2019-05-17.
  15. ↑ Barton, Mary B.; West, Carmen N.; Liu, In-Lu A.; Harris, Emily L.; Rolnick, Sharon J.; Elmore, Joann G.; Herrinton, Lisa J.; Greene, Sarah M.; Nekhlyudov, Larissa (2005). "Complications following bilateral prophylactic mastectomy". Journal of the National Cancer Institute. Monographs. 2005 (35): 61–66. doi: 10.1093/jncimonographs/lgi039 . ISSN   1052-6773. PMID   16287887.
  16. ↑ Anggraeni, Tricia Dewi; Al Fattah, Adly Nanda; Surya, Raymond (2018). "Prophylactic salpingectomy and ovarian cancer: An evidence-based analysis". South Asian Journal of Cancer. 7 (1): 42–45. doi: 10.4103/sajc.sajc_187_17 . ISSN   2278-330X. PMC   5865096 . PMID   29600234.
  17. 1 2 Obermair, Andreas; Youlden, Danny R.; Baade, Peter D.; Janda, Monika (2014-05-01). "The impact of risk-reducing hysterectomy and bilateral salpingo-oophorectomy on survival in patients with a history of breast cancer--a population-based data linkage study" (PDF). International Journal of Cancer. 134 (9): 2211–2222. doi: 10.1002/ijc.28537 . ISSN   1097-0215. PMID   24127248.
  18. ↑ "Prophylactic oophorectomy: Preventing cancer by surgically removing your ovaries". Mayo Clinic. Retrieved 2019-05-17.
  19. ↑ Moscucci, Ornella; Clarke, Aileen (March 2007). "Prophylactic oophorectomy: a historical perspective". Journal of Epidemiology & Community Health. 61 (3): 182–184. doi:10.1136/jech.2006.046474. PMC   2652903 . PMID   17325391.
  20. ↑ Church, James M.; Kalady, Matthew F. (2015-01-01). "Prophylactic colectomy: Rationale, indications, and approach". Journal of Surgical Oncology. 111 (1): 112–117. doi:10.1002/jso.23820. ISSN   1096-9098. PMID   25418116. S2CID   30857701.
  21. ↑ Church, J. M. (December 1996). "Prophylactic colectomy in patients with hereditary nonpolyposis colorectal cancer". Annals of Medicine. 28 (6): 479–482. doi:10.3109/07853899608999111. ISSN   0785-3890. PMID   9017106.
  22. ↑ Church, J. M.; Fazio, V. W.; Lavery, I. C.; Oakley, J. R.; Milsom, J.; McGannon, E. (December 1996). "Quality of life after prophylactic colectomy and ileorectal anastomosis in patients with familial adenomatous polyposis". Diseases of the Colon and Rectum. 39 (12): 1404–1408. doi:10.1007/bf02054529. ISSN   0012-3706. PMID   8969666. S2CID   21382699.
  23. ↑ Kersting, Sabine; Dimasis, Periklis; Wiesmann, Siri; Mittelkötter, Ulrich (December 2017). "[Prophylactic Appendectomy: Yes or No?]". Zentralblatt für Chirurgie. 142 (6): 607–613. doi:10.1055/s-0043-118126. ISSN   1438-9592. PMID   28985640.
  24. ↑ Newhall, Karina; Albright, Benjamin; Tosteson, Anna; Ozanne, Elissa; Trus, Thadeus; Goodney, Philip P. (September 2017). "Cost-effectiveness of prophylactic appendectomy: a Markov model". Surgical Endoscopy. 31 (9): 3596–3604. doi:10.1007/s00464-016-5391-y. ISSN   1432-2218. PMID   28078461. S2CID   19060761.
  25. ↑ Dilek, O. N.; Güler, O.; Güler, A. A.; Demirtas, I.; Altindis, M.; Dilek, F. H.; Ozgören, E. (March 2001). "Prophylactic appendectomy: is it worth to be done?". Acta Chirurgica Belgica. 101 (2): 65–67. doi:10.1080/00015458.2001.12098588. ISSN   0001-5458. PMID   11396053. S2CID   28538790.
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