Salpingectomy to reduce "ovarian cancer" risk

Tagged Salpingectomy, Ovarian Cancer, BRCA, Prophylactic; Posted 11 years ago

A few weeks ago we discussed the role of salpingectomy (without removing the ovaries) to prevent ovarian cancer. We agreed that …

• Historical data suggest that tubal ligation decreases the risk of ovarian cancer
• There are data emerging that the fallopian tube may be the origin of “ovarian” cancer in BRCA carriers
• Concept and emotions only - No scientific evidence

Some groups, such as the Canadian Gynecologic Oncology Group and others hypothesised that removing the fallopian tubes will decrease the risk of ovarian cancer. These groups advocated that all patients who have a hysterectomy for benign conditions should be counselled and given the opportunity to remove the fallopian tubes (despite poor evidence). The concept of salpingectomy has been advertised by the Canadians heavily and was taken up by media happily.

Some colleagues and I were concerned that we don’t really know what the implications and cost of salpingectomy are. Nor do we know what the impact of salpingectomy on ovarian function is.

Last week, a study was presented at the conference of the U.S. Society of Gynecologic Oncologists in Los Angeles that sheds some light on exactly that issue and that could act as a game-changer on the matter.

The study entitled “The Impact of Tubal Sterilization Techniques on the Risk of Serous Ovarian and Primary Peritoneal Carcinoma:
A Rochester Epidemiology Project (REP) Study” examined if excisional tubal sterilisation techniques account for decrease in the risk of serous ovarian cancer and primary peritoneal cancer.

This study was designed as a population-based, historical case-control study and enrolled patients from 1966 to 2010. Cases were all salpingectomies. Excision of fallopian tubes was defined as complete or partial salpingectomy, or distal fimbriectomy. Controls were matched for age and twice as many controls were enrolled as cases. Outcomes were measured as the incidence of serious ovarian and primary peritoneal cancers during the study period.

The authors from the Mayo Clinic enrolled 194 cases and 388 controls. Cases had lower parity (2 vs. 3 children) and used the oral contraceptive pill more often (33.3% vs. 4.3%). Controls were more likely to have a prior hysterectomy. Age, BMI, infertility and history of endometriosis were similar between cases and controls.

Salpingectomy cases (2.6%) had a much lower incidence of ovarian and peritoneal cancer than controls (no salpingectomy) (6.4%).

To my knowledge this is the first evidence that salpingectomy reduces the risk of ovarian cancer.

Lets just have a quick look at some of the questions that this study has not answered:

• The impact of salpingectomy on ovarian function is unclear particularly in young women;
• The degree of the preventative effect is uncertain in women who are carriers of BRCA (and have a risk of ovarian cancer in the magnitude of 40% to 80%) versus in women who have a strong family history of breast and ovarian cancer but are BRCA negative.
• The surgical implications for salpingectomy are unclear. Women will seek gynaecologists to selectively remove their fallopian tubes. There will be more surgery, more ports, more pain, more hospital stay, more unnecessary laparotomies and associated complications such as wound infections.
• Given that we always say that risk-reducing, prophylactic surgery should only be performed laparoscopically (laparotomy is out-dated for prophylactic surgery), there might even be an increase in surgical complications. Very few women may even die from procedures as a consequence of bowel and vascular injuries in the hands of non-expert laparoscopists.

Where do we go from here?

1. From now on, I will offer a salpingectomy to premenopausal women who require a hysterectomy, who will have their ovaries preserved and who look for definitive birth control.
2. I am not sure if the data are convincing enough that I would recommend a salpingectomy (and preservation of the ovaries) as a separate procedure (not associated with a hysterectomy) to women who wish to reduce her ovarian cancer risk.
3. The above data must not lead to negative outcomes and harm for patients.  Gynaecologists should document their treatment outcomes including surgical approach and conversion from laparoscopy to laparotomy, as well as complications.
4. Another study should be performed in a different geographical location. Due to differences in population, sometimes data from the U.S. and Canada don’t apply to Australia, Asia or Europe.
5. Medicare should introduce an item number specifically for salpingectomy. At present is all lumped together in item number 35638: “… ophorectomy, ovarian cystectomy, myomectomy, salpingectomy or salpingostomy, ablation of moderate or severe endometriosis requiring more than 1 hours operating time, …” Then we could merge databases from Medicare with the state-based Cancer Registries and compare incidence rates of ovarian cancer in patients who had or who did not have their fallopian tubes removed.

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