Opportunistic fallopian tube removal recommended to prevent ovarian cancer
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Clinicians should advocate for opportunistic salpingectomy among patients undergoing surgery for benign pelvic diseases to prevent ovarian cancer, according to a consensus statement from the Ovarian Cancer Research Alliance.
The Ovarian Cancer Research Alliance (OCRA) made the recommendation based on long-term follow-up of the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS) that determined current screening methods do not reduce ovarian cancer mortality.
“Given that we know that screening the general public for ovarian cancer using CA-125 and ultrasound does not save lives in the general population, and that population screening, which can reduce mortality is likely decades away, what does this mean for the ovarian cancer community?” the OCRA consensus statement reads. “It means we have an important opportunity to focus on what can improve outcomes. We have more clarity than ever before on how to best direct valuable resources to have the most impact to benefit the most people, both now and in the future.
“As the fallopian tube is the origin of most high-grade serous cancers, fallopian tube removal has been shown to dramatically reduce risk for a later ovarian cancer diagnosis,” according to the statement.
OCRA also highlighted the importance of educating patients on knowing their risk for and symptoms of ovarian cancer so they can access timely care. Specifically, clinician should encourage genetic testing for at-risk patients, emphasize visiting a gynecologic oncologist upon diagnosis, and urge family members to get tested when a patient has a genetic mutation associated with increased risk for ovarian cancer.
The original UKCTOCS data published in 2015 suggested that multimodal screening in the general population may help reduce ovarian cancer mortality via early detection. However, follow-up data published in May 2021 revealed that although multimodal screening was associated with fewer incidences of stage III or IV ovarian cancer, neither multimodal screening nor transvaginal ultrasound screening reduced cancer mortality rates.
Thus, “general population screening for ovarian and tubal cancer with either of the screening strategies cannot be recommended based on evidence to date,” Usha Menon, MD, professor of gynecological cancer at University College London and principal investigator of UKCTOCS, and colleagues wrote.
The U.S. Preventive Services Task Force also recommended in 2018 against ovarian cancer screening for women without symptoms of or known risk for the disease.
Moving forward, OCRA will “focus our larger efforts messaging that has been proven to improve outcomes for patients with ovarian cancer.” Symptom awareness will not play as significant a part in messaging, according to the statement.
References:
- Jacobs IJ, et al. Lancet. 2015;doi:10.1016/S0140-6736(15)01224-6.
- Menon U, et al. Lancet. 2021;doi:10.1016/S0140-6736(21)00731-5.
- Ovarian cancer screening and symptom awareness consensus statement. ocrahope.org/news/ovarian-cancer-screening-and-symptom-awareness-consensus-statement/. Published Jan. 30, 2023. Accessed Feb. 3, 2023.
Perspective
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Susan C. Modesitt, MD, FACS, FACOG
Ovarian cancer is one of the deadliest cancers in the United States with 19,710 cases and 13,270 anticipated deaths in 2023, down from over 22,000 expected cancers in 2017. The search for an effective ovarian cancer screening method to improve survival through early detection has been the elusive aim of decades of research into ovarian cancer. All major groups (USPSTF, FDA, ACOG, Society of Gynecologic Oncology and most recently OCRA) have recommended against ovarian cancer screening because it has not been proven effective in improving outcomes and actually may be harmful for women.
Ovarian cancer incidence rates have been decreasing 1% to 2% per year from 1990 to 2010 and really saw an accelerated decline of 3% per year from 2015 to 2019 — mortality trends are similarly promising. Reasons for this marked decline are multifactorial, but based on the best available evidence, are likely due to the following:
- Recognition that 20% to 24% of ovarian cancer is hereditary and utilizing genetic testing to identify high-risk families and enable implementation of markedly effective risk-reducing surgeries for high-risk women.
- Increased uptake of oral contraceptives, which, in turn, can decrease ovarian cancer incidence by 50% in both high-risk and normal-risk women.
- Knowledge that the majority of serous epithelial ovarian cancer arises in the fallopian tube and can be prevented by opportunistic salpingectomy (tubal removal) for women who do not desire future fertility and are having other surgeries like tubal ligation, hysterectomy or even nongynecologic surgeries (future state).
Only further research will answer the question about whether other emerging screening tests could ever tip the balance in favor of universal ovarian cancer screening, but for now, advocacy efforts should focus on achieving universal ovarian cancer prevention rather than universal ovarian cancer screening.
References:
American Cancer Society. Cancer facts and figures 2023. www.cancer.org/research/cancer-facts-statistics/all-cancer-facts-figures/2023-cancer-facts-figures.html.
Falconer H, et al. J Natl Cancer Inst. 2015;doi:10.1093/jnci/dju410.
Menon U, et al. Lancet. 2021;doi:10.1016/S0140-6736(21)00731-5.
Perets R, et al. Cancer Res. 2015;doi:10.1158/0008-5472.CAN-15-1382.
Ring KL, et al. Am J Obstet Gynecol. 2017;doi:10.1016/j.ajog.2017.04.011.
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