卵巢切除術與所有原因造成的死亡風險上升有關


  May 5, 2009 — 根據一項前瞻性、觀察性研究結果,在子宮摘除時進行雙側卵巢切除術來治療良性疾病與乳癌及卵巢癌的風險下降有關,但是會增加所有原因造成的死亡、冠狀動脈疾病以及肺癌發生率,這項研究結果發表在5月份的婦產科學期刊上。
  
  加州聖摩尼卡聖約翰健康中心約翰威尼癌症機構的William H. Parker醫師與其同事寫到,在子宮摘除時進行雙側卵巢切除術來治療良性疾病是很常進行的術式,目的在預防卵巢癌。停經前進行卵巢切除術使得內生性雌性激素與雄性激素製造下降,晚點停經被證實與死於冠狀動脈心臟疾病與中風風險下降有關,且研究結果顯示,保留卵巢功能與冠狀動脈心臟疾病風險下降有關。
  
  這項研究的目的在於比較卵巢切除術或是卵巢保留,對參與護理人員健康研究之29,380位因良性原因切除子宮之女性的影響;在這些病患中,16,345位(55.6%)接受子宮摘除與雙側卵巢切除,而13,035位(44.4%)接受子宮摘除與卵巢保留。預後評估包括因為冠狀動脈心臟疾病(CHD)、中風、乳癌、肺癌、大腸直腸癌、所有癌症、髖骨骨折、肺栓塞以及所有原因的死亡率;後續追蹤的時間為24年。
  
  相較於卵巢保留的患者,那些接受雙側卵巢切除的病患,整體死亡率的多變項危險比值(HRs)為1.12(95%信賴區間為[CI]為1.03-1.21)、致命加上非致命性CHD的HR為1.17(95% CI為1.02-1.35)、中風的HR為1.14(95% CI為0.98-1.33)。在卵巢切除術後,發生乳癌的風險下降(HR為0.75;95% CI為0.68-0.84)、發生卵巢癌的風險同樣下降(HR為0.04;95% CI為0.01-0.09;治療所需人數為220人)、且包括整體癌症發生率(HR為0.90;95% CI為0.84-0.96)。然而,發生肺癌的風險則是上升的(HR為1.26;95% CI為1.02-1.56;造成傷害所需人數190人),整體癌症死亡風險同樣也是上升的(HR為1.17;95% CI為1.04-1.32)。
  
  對從未使用雌性激素療法的女性,50歲以前接受雙側卵巢切除術,與所有原因的死亡率、CHD與中風風險增加有關。在手術後35年的生命之間,每9位接受卵巢切除術患者就會有1位死亡。
  
  研究作者寫到,相較於卵巢保留,於子宮摘除術處理良性疾病時,進行雙側卵巢切除術,與乳癌與卵巢癌風險下降有關,但是增加所有原因死亡的風險,還有致命與非致命性冠狀動脈心臟疾病與肺癌的風險。在任何分析與年齡層中,沒有一個是卵巢切除術與增加存活率有關的。
  
  這項研究的限制包括,觀察性研究設計、自願性選擇卵巢切除相較於卵巢保留在組與組之間可能未經校正的差異,以及缺乏應用在非白人人種上的一般性。
  
  研究作者的結論是,如果這對病患沒有明顯的好處,就不應該進行預防性手術;因此,預防性卵巢切除術,透過降低卵巢癌風險來達到改善存活的目標,我們的研究結果似乎沒有支持這樣的看法。有鑑於在美國每年有300,000女性接受選擇性卵巢切除術,這些發現對公共衛生將有很大的意義。
  
  Ethicon女性健康與健康分析研究合作夥伴贊助這項研究。其中5位研究作者與Ethicon女性健康與健康分析研究合作夥伴、世界衛生組織、以及/或是國家衛生研究院健康分析研究與另類醫學有許多的資金往來。其他的研究作者表示沒有相關的資金往來。
  

Oophorectomy Linked to Increased Risk for All-Cause Mortality

By Laurie Barclay, MD
Medscape Medical News

May 5, 2009 — Bilateral oophorectomy during hysterectomy for benign disease is associated with a decreased risk for breast and ovarian cancer but an increased risk for all-cause mortality, coronary disease, and lung cancer, according to the results of a prospective, observational study reported in the May issue of Obstetrics & Gynecology.

"Bilateral oophorectomy at the time of hysterectomy for benign disease is commonly practiced to prevent subsequent development of ovarian cancer," write William H. Parker, MD, from the John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, California, and colleagues. "Oophorectomy before menopause leads to an abrupt reduction in endogenous estrogen and androgen production....Later age of menopause has been associated with a reduced risk of death from coronary heart disease and stroke, and studies show that preserving ovarian function is associated with a lower risk of coronary heart disease."

The goal of this study was to compare long-term health outcomes and mortality after oophorectomy or ovarian conservation in 29,380 women participants of the Nurses' Health Study who had a hysterectomy for benign disease. Of these, 16,345 (55.6%) had hysterectomy with bilateral oophorectomy, and 13,035 (44.4%) had hysterectomy with ovarian conservation. Outcome measures included incident events or death caused by coronary heart disease (CHD), stroke, breast cancer, ovarian cancer, lung cancer, colorectal cancer, total cancer, hip fracture, pulmonary embolus, and all-cause mortality. Duration of follow-up was 24 years.

Compared with women who had ovarian conservation, those who had bilateral oophorectomy had multivariable hazard ratios (HRs) of 1.12 (95% confidence interval [CI], 1.03 - 1.21) for total mortality, 1.17 (95% CI, 1.02 - 1.35) for fatal plus nonfatal CHD, and 1.14 (95% CI, 0.98 - 1.33) for stroke. After oophorectomy, risks decreased for breast cancer (HR, 0.75; 95% CI, 0.68 - 0.84), ovarian cancer (HR, 0.04; 95% CI, 0.01 - 0.09; number needed to treat, 220), and total cancers (HR, 0.90; 95% CI, 0.84 - 0.96). However, risks increased for lung cancer (HR, 1.26; 95% CI, 1.02 - 1.56; number needed to harm, 190) and total cancer mortality (HR, 1.17; 95% CI, 1.04 -1.32).

For women who had never used estrogen therapy, bilateral oophorectomy before age 50 years was associated with an increased risk for all-cause mortality, CHD, and stroke. Assuming a 35-year life span after surgery, 1 additional death would be expected for every 9 oophorectomies performed.

"Compared with ovarian conservation, bilateral oophorectomy at the time of hysterectomy for benign disease is associated with a decreased risk of breast and ovarian cancer but an increased risk of all-cause mortality, fatal and nonfatal coronary heart disease, and lung cancer," the study authors write. "In no analysis or age group was oophorectomy associated with increased survival."

Limitations of this study include observational design, self-selected oophorectomy vs ovarian conservation, possible uncorrected differences between the groups, and lack of generalizability to nonwhite women.

"Preventive surgery should not be performed if it does not clearly benefit the patient," the study authors conclude. "Therefore, prophylactic oophorectomy, with the goal of improving survival by reducing ovarian cancer, seems not to be supported by our study. Given that approximately 300,000 U.S. women per year undergo elective oophorectomy, these findings have important public health implications."

Ethicon Women's Health and the Partnership for Health Analytic Research funded this study. Five of the study authors have disclosed various financial relationships with Ethicon Women's Health, Partnership for Health Analytic Research, World Health Organization, and/or the National Institutes of Health National Center of Complementary and Alternative Medicine. The remaining study authors have disclosed no relevant financial relationships.

Obstet Gynecol. 2009;113:1027-1037.

    
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