Detecting ovarian cancer is difficult. While there are screening programs for people with increased inherited or genetic risk of developing ovarian cancer, even when diagnosed the disease more often than not has reached an advanced stage. Outcomes for ovarian cancer remain poor—it’s the fifth most common cause of cancer deaths in women and accounts for more deaths than any other cancer of the female reproductive system.
A growing body of evidence points to the fallopian tubes—and not the ovaries—as the point of origin of ovarian cancer. Recently, the Ovarian Cancer Research Alliance (OCRA) issued a statement calling for those who are having pelvic surgeries for noncancerous conditions to consider having their fallopian tubes removed, a procedure known as opportunistic salpingectomy, as a way to prevent ovarian cancer. Gynecologic oncologists at NYU Langone’s Perlmutter Cancer Center said the recommendation is directed at women at average risk of ovarian cancer who are no longer having children and already having a pelvic procedure, such as a hysterectomy, a cyst removal, treatments for endometriosis or a tubal ligation.
Eva Chalas, MD, a gynecologic oncologist and physician director of Perlmutter Cancer Center at NYU Langone Hospital—Long Island, said OCRA’s statement renews earlier recommendations from the Society of Gynecologic Oncology (SGO) and the American College of Obstetrics and Gynecology—issued in 2013 and 2015, respectively—that obstetrician–gynecologists discuss opportunistic salpingectomy with patients who are at average risk for developing ovarian cancer.
“The SGO recommendation was developed primarily because data from patients who had their fallopian tubes and ovaries removed, including in those who had cancer, suggested the presence of precursor ovarian cancer lesions in the fallopian tubes in about 75 percent of patients,” said Dr. Chalas, who is also a professor in the Department of Obstetrics and Gynecology at NYU Long Island School of Medicine. “The emphasis of the statements of both groups is that physicians and patients discuss the implications of removing the fallopian tubes as a preventive measure so patients can make an informed decision.”
The statement issued by OCRA stems from the results of a large clinical trial called UKCTOCS, which found that screening average-risk women with currently available screening methods—measuring blood levels of the CA-125 protein and ultrasound—does not reduce deaths from ovarian cancer, even if the women received a diagnosis at an early stage of the disease.
Removing only the fallopian tubes carries the additional benefit of preserving the function of the ovaries, which secrete the hormones estrogen and progesterone. Removal of the ovaries, a procedure called oophorectomy, can induce early-onset menopause, which carries its own risk for developing cardiovascular disease and osteoporosis, along with other side effects.
“We have a lot of good data that say preserving a person’s ovaries as long as possible is beneficial in terms of heart and bone health, as well as memory and cognition,” said Deanna Gerber, MD, a gynecologic oncologist at Perlmutter Cancer Center on Long Island. “Determining who needs which surgery, whether it is salpingectomy or oophorectomy, and how we can keep a woman’s ovaries in as long as possible will translate into a big benefit in terms of survival.”
The current recommendations for opportunistic salpingectomy are focused on reaching obstetrician–gynecologists, who are already offering this procedure to women at the time of hysterectomy and for those opting for sterilization procedures, including at a cesarean delivery, but Dr. Gerber suggests that the focus should be expanded to all surgeons.
“There are a lot of women having procedures in the pelvis—colorectal, bladder, and even gallbladder surgeries—that might be a great opportunity for removal of the fallopian tubes as well,” said Dr. Gerber, who is also a clinical assistant professor in the Department of Obstetrics and Gynecology.
Dr. Chalas suggests that surgeons performing abdominal procedures could partner with gynecologists or, if they feel confident in performing salpingectomies, perform salpingectomies themselves. She also recommends that colorectal cancer surgeons should consult with gynecologists because some women will carry the genetic mutation for Lynch syndrome. People with this condition may have up to an 80 percent chance of developing colorectal cancer over a lifetime and a significantly increased risk of developing not only fallopian tube and ovarian cancers, but also uterine cancer.
All postmenopausal women with colon cancer should be offered removal of tubes and ovaries at the time of colon cancer surgery, Dr. Chalas said. A similar recommendation should be discussed with premenopausal women who will require chemotherapy or radiation after their surgery, since such treatment is likely to cause menopause, and yet the ovaries may be at risk.
“Raising awareness of the fact that other organs of the body may be impacted is really important,” Dr. Chalas said. “As a gynecologic oncologist, I have operated on a number of women with rapidly increasing size ovarian mass caused by metastatic colon cancer. That surgery could have been avoided if removal of tubes and ovaries was considered at the time of colon cancer surgery.”