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Salpingectomy may reduce risk for ovarian cancer
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Surgical removal of the fallopian tubes may help reduce a woman’s risk for ovarian cancer even if her ovaries are left intact, according to study results.
The findings support prior research that suggests a considerable proportion of ovarian cancers begin in the fallopian tubes or uterus, potentially contributing to late-stage diagnoses and poor outcomes.
“Ovarian cancer remains the most lethal gynecological cancer in developed countries, and efforts to prevent the disease have been unsuccessful,” Henrik Falconer, MD, PhD, of the department of medical epidemiology and biostatistics and the department of women’s and children’s health at Karolinska Institutet in Sweden, told HemOnc Today. “Emerging data suggest that ovarian cancer arises outside the ovaries, and studies of microdissected fallopian tubes from BRCA-mutation carriers have identified preinvasive lesions.”
Henrik Falconer
Falconer and colleagues conducted a large population-based cohort study to assess whether removal of fallopian tubes on benign indication is associated with a reduced risk for ovarian cancer.
The researchers used data from several nationwide health care registries in Sweden to identify 251,465 women who underwent one of four surgeries on benign indication — sterilization, salpingectomy, hysterectomy, or hysterectomy and concomitant bilateral salpingo-oophorectomy (BSO) — between 1973 and 2009. They compared ovarian cancer incidence among those women to that observed in a control group of 5.44 million women.
A subanalysis looked at both one-sided and two-sided salpingectomy. All statistical measures were two-sided.
Results showed women who underwent salpingectomy demonstrated a significantly reduced risk for ovarian cancer compared with the unexposed population (HR = 0.65; 95% CI, 0.52-0.81).
They also identified significant risk reductions among women who had undergone hysterectomy (HR = 0.79; 95% CI, 0.7-0.88), sterilization (HR = 0.72; 95% CI, 0.64-0.81) and hysterectomy with BSO (HR = 0.06; 95% CI, 0.03-0.12).
Results showed a 50% decrease in risk for ovarian cancer associated with bilateral salpingectomy (HR = 0.35; 95% CI, 0.17-0.73) compared with unilateral salpingectomy (HR = 0.71; 95% CI, 0.56-0.91).
“These data support the hypothesis that ovarian cancer mainly originates from the fallopian tubes,” Falconer said. “We further believe that salpingectomy could constitute a less radical approach in [risk-reducing salpingo-oophorectomy] among BRCA mutation carriers. Finally, women scheduled for hysterectomy should most likely have their fallopian tubes removed at the same time.”
In an accompanying editorial, Elizabeth Poole, MD, of the Channing Division of Network Medicine at Brigham and Women’s Hospital and Harvard Medical School, and colleagues cautioned that the study — although large — had several limitations. These include the small number of ovarian cancer diagnoses, and the researchers’ limited ability to control for potentially important confounders, such as the use of oral contraceptives.
“[Also], this study did not specifically address risk of high-grade serous tumors, the tumors that putatively arise in fallopian tubes,” Poole and colleagues wrote. “If the authors could have demonstrated that salpingectomy specifically prevents these types of tumors, they would have provided stronger evidence for the potential of this surgery to prevent this aggressive tumor subtype.”
However, Poole and colleagues called the study “a very important first step” in the effort to produce population-level evidence to show the preventive effects of salpingectomy.
“Replication of these results and further evaluation of the long-term health impacts of salpingectomy are needed so that women who elect salpingectomy alone instead of BSO do so with a realistic understanding of both the potential complications of this procedure and the degree to which it will protect them from a high-grade serous cancer later in life,” Poole and colleagues wrote. “Given the large numbers of women who are now undergoing opportunistic salpingectomy, the long-term safety and efficacy of this procedure should be resolved over the next two decades and we will see if salpingectomy yields tangible benefits in terms of preventing the most aggressive form of ovarian cancer.” – by Anthony SanFilippo
For more information:
Henrik Falconer, MD, can be reached at Karolinska Institutet, Department of Medical Epidemiology and Biostatistics, SE-171 77 Stockholm, Sweden; email: Henrik.Falconer@Karolinska.se.
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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Stephanie V. Blank, MD
As the fallopian tube has emerged as a putative site of origin of ovarian cancer, several clinical questions regarding ovarian cancer risk reduction have come to forefront. Falconer and colleagues hypothesized that surgical removal of fallopian tubes would result in reduced risk for ovarian cancer, and used Sweden’s quite comprehensive health care registry to perform a cohort study to test this idea. The issue here is in determination of exposures: Women are generally born with five intrapelvic gynecologic organs (one uterus, two tubes, two ovaries) and can have surgical removal or alteration of one or any combination of the five. This leads to many permutations in the procedure performed.
The study attempts to define four distinct exposures: removal of uterus, tubes and ovaries; removal of tubes; sterilization; hysterectomy alone, as well as no exposure. Again, it is difficult to compare the groups here because classification is not straightforward, and the statement “oophorectomy without concomitant hysterectomy was not considered a unique exposure” is baffling when trying to examine the surgery’s future effect on ovarian cancer risk.
How to know which is more important, removal of the tubes vs removal of the ovaries, for cancer risk reduction if there is no group with ovaries removed and tubes in situ?
So although I have some issue with basic methods and study design and would not necessarily call this article “robust epidemiologic support for the hypothesis that ovarian cancer arises primarily in gynecologic organs outside the ovaries,” I do welcome the discussion it provokes:
1. Should gynecologists routinely remove tubes when performing hysterectomy for benign indication for the purpose of ovarian cancer risk reduction, even when retaining ovaries, as has been proposed by British Columbia and others? This seems not unreasonable, but this study — which excluded patients undergoing hysterectomy plus salpingectomy — does not answer this question.
2. Should salpingectomy be preferred to other forms of female surgical sterilization for the purpose of ovarian cancer risk reduction? This study does show a trend toward improved ovarian cancer risk reduction with salpingectomies vs sterilization, but there is no discussion re: operative morbidity or cost, so this study cannot be used as evidence to answer this question as yet.
3. Should salpingectomy with delayed oophorectomy be considered an acceptable intermediate risk reduction strategy for women desiring surgical risk reduction but not yet willing to accept the side effect of menopause? This would need to be determined prospectively and not via registry. I do support this strategy as a compromise in specific situations, but I would not consider Falconer’s study as evidence to support this decision.
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