Douglas A. Levine, MD

The hereditary breast/ovarian cancer syndrome is responsible forapproximately 5% of all breast cancers and 10% of all ovarian cancers.Although this accounts for a small portion of these diseases, muchattention has been focused on this syndrome because of the abundanceof research in this area. The majority of the hereditary breast/ovariansyndrome can be attributed to germ-line mutations in the BRCA1 andBRCA2 genes. Reliable screening techniques for these mutations havebeen developed and are readily available in clinical practice. Forpatients who are thought to have the hereditary breast/ovarian cancersyndrome based on family history or genetic testing, options exist foreither intensive screening or prophylactic surgery. This review willdiscuss the mechanisms by which mutations in the BRCA genes lead tothe development of cancer, the limitations of currently available screeningtechniques, and the efficacy of prophylactic surgery. In general,prophylactic oophorectomy can be performed laparoscopically as anoutpatient procedure, carrying as its main drawback the associatedconsequence of surgical menopause. Prophylactic mastectomy is quiteeffective in reducing the risk of breast cancer but is a more extensivesurgical procedure and results in disfigurement. For any given patient,the best estimates of individual risk of breast or ovarian cancer shouldbe weighed against the benefits of prophylactic surgery and the patient’spersonal wishes.

The aging population poses new challenges to all fields of medicine and to gynecologic oncology in particular. In gynecologic oncology, issues that are germane to general medicine, cancer chemotherapy, radical surgery, and routine gynecology are all encountered on a regular basis. In clinical practice, the "very old" are often thought to tolerate standard treatments poorly. While comorbid conditions may be more prevalent, management decisions should be based on an assessment of individual function and not solely on numerical age. In the article by Mirhashemi and colleagues, this theme is conveyed throughout, as they describe the current management of gynecologic malignancies in older women.