Salpingectomy for “Ovarian” Cancer Prevention

Posted 12 years ago

Earlier this year we witnessed some hype that removing the fallopian tubes (salpingectomy) would prevent ovarian cancer. Apart from the hype, I never found a clear and precise summary of the evidence; most likely because there is actually little or no evidence on the issue. Lets just nail down a few dot points:

• Ovarian cancer is not uncommon. The risk of ovarian cancer for a woman in the developed world is roughly 1 in 80.
• Most ovarian cancers are diagnosed at advanced stages and survival chances are generally poor.
• Screening for ovarian cancer is ineffective.
• Most ovarian cancers originate from serous epithelium that has only three possible sources: ovarian surface epithelium, fallopian tube, peritoneum.
• Bilateral Salpingo-Oophorectomy (BSO) in women under the age of 49 years leads to early menopause and those women carry a significantly higher risk of morbidity and even death from cardiovascular and other complications.

There is absolutely no direct evidence (data) suggesting that salpingectomy (without oophorectomy) has a benefit on ovarian cancer incidence or mortality. No study whatsoever has been carried out to suggest that women who had a salpingectomy did better than women who did not have the fallopian tubes removed. No randomised trial, no population-based data set, and not even any retrospective series are available as far as I am aware.

How about indirect evidence?

1. Incidentally (at the time of risk-reducing prophylactic BSO) found “serous” cancers were located in the distal end of the fallopian tube in 40% to 60% of cases.
2. A transition from normal to precancerous and cancerous serous cells has been identified in the fallopian tube (but not in the ovary).
3. Salpingectomy causes extremely low morbidity (especially when performed as part of a hysterectomy). It does not induce early menopause.

The idea that removing the fallopian tubes prevents “ovarian” cancer is only a concept at this stage but I think it is worthwhile exploring.

It may require a large dataset in order to pick up a small effect. If only 1 in 80 women develop ovarian cancer and “ovarian” cancer and in half of all these patients it develops in the fallopian tube, we need to have an enormous data set to identify a signal.

Health administration data collected by health departments would be ideal to use for that purpose.  The use of health administration data require linking of various data sets and will represent a far more accurate model than retrospective series of selected patients. Such data were used in the UK, in the USA and in Australia previously.

In Australia those data might be difficult to obtain. First, the Australian coding for hysterectomy does not differentiate whether the fallopian tube or the ovaries (unilaterally or bilaterally) were removed at surgery. Secondly, the fallopian tubes are commonly left intact when the ovaries are preserved during a hysterectomy.

I am also concerned that prospective data will require an enormous effort and might take long to be available for our decision-making.

For now, we as gynaecologists might wish to change the way we discuss this issue with our patients:

Until recently, I discussed the issue of ovarian preservation (leaving ovaries and fallopian tubes) with all my premenopausal patients who are booked for a hysterectomy. I have standard procedures in place to inform patients about the proposed benefits and the drawbacks of BSO and my consent form reflects the discussion we had about this issue preoperatively. So far, I have not discussed the issue of fallopian tubes and ovaries separately until recently.

As a profession and as gynaecologists, we should amend that. Recently, I updated my patient information sheet and distinguish between ovarian preservation, removal of fallopian tubes or removal of ovaries plus fallopian tubes.

A different group of patients who might benefit from a similar discussion are patients requesting a tubal ligation for permanent contraception.

Another group of patients includes those who are BRCA positive and who are at enormous risk of developing ovarian cancer.  Most patients are keen to have both their ovaries and fallopian tubes removed but some patients are extremely concerned about the hormonal and menopausal effects. While removing only the fallopian tubes might not be standard management, it could be a reasonable option for selected women.

I hope you enjoyed the first year of the Gynaecology Blog. I will take a couple of weeks vacation and will be back with blogging on the 11 January.

I would also like to thank all readers of the blog for their thoughtful comments and wish all of you a very Merry Christmas and New Year.

Also, readers in Australia should keep in mind that the Battle Against Ovarian Cancer is on. For more info and to support gynaecological cancer research - go to www.battleagainstovariancancer.org