In this prospective study, women undergoing RRSO were more likely to report short-term deficits in physical functioning and sexual functioning compared to women in the screening group. However, by 12-month follow-up, ratings of QOL were similar between the two groups. These findings are consistent with data from prior retrospective studies that reported comparable levels of QOL between women who had RRSO and those who chose screening [16
As would be expected, decrements in QOL following surgery were observed in domains related to physical functioning, physical role limitations, pain, and vitality. Because social interactions are likely to be more limited during the recuperative period immediately following surgery, this may account for the decline in social functioning observed at 1-month post-surgery. Across most subdomains of QOL, recovery to baseline levels was observed by 6-months post-surgery. However, for bodily pain, women who had had RRSO continued to report greater pain at 12-month follow-up. The reasons for this finding are unclear, as women in the surgery group were not more likely to report symptoms (e.g., joint pain or general aches) than women in the screening group.
Overall, a greater proportion of women who had RRSO reported symptoms of estrogen deprivation (i.e. hot flashes, vaginal dryness) compared to women in the screening group. Although this would be expected following surgically-induced menopause, it should be noted that these differences were already evident at baseline (prior to surgery). One possible interpretation is that, even though the two groups were similar in age, women who chose surgery were already in a peri-menopausal state of diminished production of estrogen. Although speculative, it is possible that women who perceive that they are imminently approaching menopause are more accepting of surgically-induced menopause, and therefore, are more likely to commit to having RRSO.
In addition, our findings indicated that symptoms of vaginal discomfort decreased over time, notably among women who had had RRSO. This gradual decrease in the experience of vaginal discomfort may reflect better awareness and coping with post-menopausal symptoms among women who are dealing with the physical side effects of surgically-induced menopause. That is, over time, women who had RRSO may have learned how to better manage these symptoms so as to reduce discomfort, perhaps through seeking information or advice from their physicians, healthcare providers, the internet, or other women.
Although the two groups differed in their symptom experience (particularly in those symptoms associated with estrogen deprivation), there were few differences in quality of life between the two groups at long-term (i.e. 6-month and 12-month) follow-up. It has been noted that experiencing more symptoms does not necessarily translate to lower quality of life [31
], and that the two concepts (symptoms and QOL) represent distinctive entities and are not interchangeable, which is reflected by the generally modest overlap between symptoms and QOL reported in most studies [32
]. A study of symptoms and QOL in breast cancer patients reported that fatigue was the strongest predictor of QOL, whereas other symptoms (e.g., pain, nausea and/or vomiting, breast symptoms, systemic therapy side effects, and arm symptoms) explained very little of the variance in QOL scores [32
]. Hence, in the context of the present study, the finding that QOL did not differ between the two groups even though the surgical group experienced greater symptoms may be attributed, in part, to the fact that the most commonly reported symptoms by women in our study were not ones found to be strongly associated with QOL in other previous studies. Finally, it has been proposed that patients likely “adapt” to any physical changes that occur over time, so that QOL tends to remain stable. This concept has been termed “response shift,” which is defined as a recalibration or change in one’s internal standards of QOL [33
]. Whether women who undergo RRSO experience a response shift in QOL following surgery remains to be investigated.
Similar to previous studies that have reported sexual dysfunction following RRSO [15
], women in the surgery group reported greater discomfort and less satisfaction with sexual intercourse compared to women in the screening group. However, our pattern of findings indicates a more complex story. Specifically, our data suggest that sexual satisfaction in older women is not as adversely affected by surgery, unlike in younger women. For older women who may have already been experiencing menopausal symptoms pre-surgery (e.g., vaginal dryness), the post-surgical manifestations of menopause may not be so dramatically different or require as considerable adjustment after surgery. Indeed, this is consistent with a previous study in which postmenopausal women reported no adverse effects of RRSO on their libido [11
]. For younger women, however, coping with surgically-induced menopause may require greater adjustment [34
], and thus, the physical and psychological consequences of menopause may have a greater negative impact on sexual functioning [36
In general, older women had fewer depressive symptoms and greater psychosocial functioning (i.e. higher MCS scores) than younger women. These data are consistent with previous studies of breast cancer patients that have reported older age to be positively associated with psychosocial adjustment [37
]. Previous studies indicate that younger women may have worse symptom experiences [39
]; as such, the transition to menopause can be associated with decreases in QOL and greater emotional distress [40
]. In addition, it has been proposed that younger women may have fewer coping strategies and experience greater disruptions in their daily responsibilities compared to older women [40
], which could contribute to depressive symptoms and poorer psychosocial adjustment.
As one of the first studies to present prospective data on QOL over time among a sample of at-risk women who choose to undergo RRSO or serial screening, these findings may be useful for helping at-risk women make decisions about their ovarian cancer prevention options. Although there are a number of strengths of the study, including the prospective design, the cohort of two comparable groups of women with respect to demographic variables, and a longitudinal follow-up, we acknowledge several limitations of the study. First, the sample size is relatively small, although comparable to other prospective studies of this nature [19
]. Second, the majority of women who underwent RRSO in the present study had either abdominal BSO or concomitant abdominal hysterectomy. Given that prior studies have reported that short-term quality of life outcomes are generally higher among women undergoing laparoscopic procedures compared to total abdominal hysterectomy in the first 6 weeks following surgery [43
], the 1-month post-surgical data may be less applicable to women who undergo laparoscopic procedures. Third, our sample was comprised of women who were predominantly non-Hispanic white and well-educated, thereby limiting the potential generalizability of these results to other ethnic/racial groups or women with fewer years of education. Fourth, because study participants were recruited from a cancer risk assessment program, the majority of women had already undergone previous cycles of screening (i.e. were not screen naïve) when they entered the study. As such, screening may be less likely to have had a negative impact on quality of life among women with a history of prior screening. On the other hand, if there was a selection bias for including participants who have previously tolerated screening well from a quality of life standpoint, then this bodes well for the surgery group, as they had levels of QOL comparable to the screening group. Finally, we acknowledge that the two groups were not equivalent with respect to prior breast cancer history. However, all women were disease-free and baseline levels of QOL did not differ between the surgery and screening groups. In other words, given that a significantly greater proportion of women in the surgery group had had breast cancer, one might expect to see lower levels of QOL in this group compared to the screening group at baseline, but this was not the case. Despite these potential limitations, the findings from the present study provide a greater understanding of how various cancer prevention options may impact on women’s physical, psychosocial, and sexual functioning over time, and how these effects may be more salient among younger women.
In sum, findings from the present study suggest that, although there are short-term decrements in specific domains of QOL following RRSO, most women recover baseline functioning within one year. However, issues regarding the potential impact of surgery on sexual functioning should be considered and weighed carefully, particularly among younger women. New data demonstrating differences in age of onset of ovarian cancer by gene affected [9
], coupled with the present findings, can assist women and their health care providers in better customizing RRSO recommendations.