Reducing Ovarian Cancer Risk With Opportunistic Salpingectomy

Ovarian cancer is the most lethal gynecologic malignancy, with a five-year survival rate of 50.9%.

“One of the difficulties in improving the survival rate is that approximately 70% of patients present with stage III and stage IV disease,” says Peter Rose, MD, a gynecologic oncologist at Cleveland Clinic. “Efforts to screen have been uniformly unsuccessful because there are no specific symptoms, and we have no effective screening for early-stage ovarian cancer.”

Dr. Rose is among a growing group of obstetricians and gynecologists advocating opportunistic salpingectomy to help prevent ovarian cancer. In August, the American College of Obstetricians & Gynecologists released a Clinical Practice Update, which further supports bilateral salpingectomy as a safe and effective method of reducing lifetime risk of ovarian cancer.

Fallopian tube removal can be done during common procedures inside the abdomen or pelvis, such as hysterectomy, cholecystectomy, bariatric surgery and colorectal surgery, increasing the operative time by only eight minutes.

Origins of ovarian cancer

Support for opportunistic salpingectomy reflects an evolution in understanding where ovarian cancer originates.

“It is now recognized that there are two mechanisms of ovarian carcinogenesis,” says Dr. Rose. “The most common high-grade serous carcinoma — comprising 70% of ovarian cancer — arises from the fallopian tube. Less common ovarian cancers may arise from the ovary or from endometriosis.”

Normal cells become malignant when genetic damage activates oncogenes and inactivates tumor suppressors, allowing a single cell clone to expand and evolve into a tumor. The most common mutation in ovarian cancer involves the p53 tumor suppressor gene.

Studies of patients with genetic mutations in the BRCA1 and BRCA2 gene provide insight into ovarian carcinogenesis. Patients with BRCA-mutation are at the highest risk of developing ovarian cancer and comprise approximately 20% of all patients with ovarian cancer.

One study revealed that prophylactic risk-reducing salpingo-oophorectomy in BRCA-mutated patients decreased the risk of ovarian cancer. In addition, studies of their fallopian tubes demonstrated precursor lesions with p53 mutations known as serous intra-epithelial carcinoma (STIC).

“Most STIC lesions are benign, but about 20% of patients develop peritoneal cancer at 10 years,” says Dr. Rose. “The high-grade serous carcinoma probably derive from the fallopian tube, and exfoliated tumor cells from the fimbriae drop onto the ovaries.”

Complementary procedures

There is no functional purpose to the fallopian tubes after a woman has completed childbearing. Therefore, it is sensible to reduce ovarian cancer risk by performing opportunistic salpingectomies on these patients when they are already undergoing another surgery, says Dr. Rose.

“There are many opportunities to take out fallopian tubes,” he says. “Tubal litigation is chosen by 39.1% of women over 40 as a primary means of sterilization. Approximately 5.6% of the U.S. population undergoes cholecystectomy, and 73% of those patients are female. Around 80% of patients who undergo bariatric surgery are female.”

Data support opportunistic salpingectomy: A landmark study conducted in British Columbia and published in JAMA Network Open revealed that the prevention strategy reduces the risk of high-grade serous carcinoma by 80%.

Increasing advocacy

During the NRG Oncology Semiannual Meeting in July, Dr. Rose and colleagues Lindsay Beffa, MD, Kevin Elias, MD, and Sarah Lynum, MD, attended an educational symposium on ovarian cancer prevention that included conversations about opportunistic salpingectomy and the importance of spreading the message about the procedure.

“We want to increase advocacy for opportunistic salpingectomy among women and healthcare providers,” says Dr. Rose. “The only thing better than a cure for ovarian cancer is never needing one.”