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DOI: 10.1055/s-2006-924303
Georg Thieme Verlag KG Stuttgart · New York
Prophylaktische Chirurgie bei Brust- und Eierstockkrebsrisiko. Ein Überblick über die internationale Forschungsliteratur zu Einstellungen, Inanspruchnahmeverhalten und Lebensqualität
Prophylactic Surgery in Women at High Risk for Breast and Ovarian Cancer. An Overview of the International Literature on Attitudes, Uptake and Quality of LifePublication History
Eingang Manuskript: 17.1.2006
Eingang revidiertes Manuskript: 18.4.2006
Akzeptiert: 28.4.2006
Publication Date:
04 December 2006 (online)
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Zusammenfassung
Fragestellung: Risikopatientinnen für familiäres Mamma- und Ovarialkarzinom, insbesondere Mutationsträgerinnen im BRCA1 und BRCA2-Gen können derzeit nur begrenzt Präventionsmöglichkeiten angeboten werden. Die prophylaktische Mastektomie und Ovarektomie stellt neben der Chemoprävention die derzeit einzige Primärprävention dar. In dem Beitrag werden Studien zu den Einstellungen von Risikopersonen und von Experten zu prophylaktischer Chirurgie, dem tatsächlichen Inanspruchnahmeverhalten, sowie der Langzeitzufriedenheit und der Bewältigung prophylaktischer Operationen zusammengefasst. Methodik: Das systematische Review stützt sich auf die Auswertung von deutsch- und englischsprachigen, medizinischen und psychologischen Datenbanken. Ergebnisse: Die prophylaktische Chirurgie bei hereditärem Mamma- und Ovarialkarzinom wird international sehr unterschiedlich in Anspruch genommen. So entscheiden sich zwischen 3 und 67 % der Risikopersonen für eine prophylaktische Mastektomie, 13 bis 64 % für eine prophylaktische Ovarektomie. Die Einstellungsstudien zeigen entsprechend ähnlich große Unterschiede im internationalen Vergleich, welche auf unterschiedliche Beratungsstrategien zurückzuführen sind. Eine hohe Risikowahrnehmung, krebsspezifische Ängste und die ärztliche Empfehlung sagen neben dem objektiven Erkrankungsrisiko die Entscheidung für eine prophylaktische Brustentfernung vorher. Ärzte männlichen Geschlechts raten zudem häufiger zu prophylaktischen Operationen als ihre Kolleginnen. Die vorliegenden Studien zur Zufriedenheit und Bewältigung von prophylaktischen Operationen sind großteils retrospektiv und nur wenige Studien beziehen sich auch auf Patientinnen, deren Eingriff mehrere Jahre zurückliegt. Die vorliegenden Studien weisen neben der objektiven Risikoreduktion auch auf eine psychische Entlastung der betroffenen Frauen hin. Ein kleiner Teil bedauerte den Eingriff im Nachhinein. Schlussfolgerung: Insbesondere bei einer prophylaktischen Chirurgie ist eine informierte Entscheidung und das Einhalten einer Bedenkzeit unabdinglich. Gleichzeitig sollten andere Möglichkeiten der Risikoreduktion, wie etwa Chemoprävention, ausführlich erläutert werden.
Abstract
Purpose: Currently, only limited preventive interventions are available to women who carry BRCA1 or BRCA2 mutations or who are at increased risk for breast and ovarian cancer. Prophylactic mastectomy and oophorectomy are, in addition to chemoprevention, the only primary prevention up to now. In this review studies of the attitudes, decision making, coping and long term satisfaction of high risk women and of the attitudes of health care professionals are the main outcome variables. Methods: The review is based on the analysis of German and English databases with a search of both medical and psychological databases until 2005. Results: Performance of prophylactic surgery for hereditary breast and ovarian cancer varies widely internationally. 3 % to 67 % of women at risk or mutation carriers elect to undergo prophylactic mastectomy and between 13 % to 64 % choose to undergo prophylactic oophorectomy. Studies examining attitudes towards prophylactic mastectomy and oophorectomy show similarly diverse results. Different counseling strategies may account for this finding. Heightened risk perception, cancer specific anxiety and physicians' recommendations affect, in addition to the objective disease risk, the decision for prophylactic mastectomy. In addition male physicians recommend prophylactic surgeries more often than female physicians. Studies focusing on satisfaction and coping with prophylactic surgery are mostly retrospective and only few studies include women, with a longer follow up. In addition to the objective risk reduction the studies suggest that prophylactic surgery is associated with a considerable reduction in psychological distress which counterbalances the impairment in body image and endocrine symptoms. Very few women regretted the decision to undergo prophylactic surgery. Conclusion: Informed decision making and time to consider is crucial when women consider prophylactic surgery. At the same time other less invasive methods of risk reduction such as chemoprevention should be extensively discussed.
Schlüsselwörter
Hereditäres Mamma- und Ovarialkarzinom - prophylaktische Chirurgie - Inanspruchnahmeverhalten - Langzeitzufriedenheit - Beratung
Key words
Hereditary breast and ovarian cancer - prophylactic surgery - decision making process - long term satisfaction - counseling
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Dr. phil. Andrea Vodermaier
Klinik und Poliklinik für Frauenheilkunde und Geburtshilfe - Großhadern, Ludwig-Maximilians-Universität München
Marchioninistraße 15
81377 München
Email: Andrea.Vodermaier@med.uni-muenchen.de