Ovarian Cancer Canada

Western Regional Blog – BC, YK, AB, NWT and Nunavut

Ovarian Cancer Focus in Current Oncology

This issue of Current Oncology contains four articles on the subject of the role of bilateral salpingectomy in preventing high-grade serous ovarian carcinoma. To the uninitiated, that idea may seem counterintuitive. Surely, to prevent ovarian carcinoma, you have to remove the ovaries, and not the adjacent fallopian tubes? Well, maybe not. The four articles, in their various ways, make plain that the focus of prevention in high-grade serous ovarian carcinoma has shifted from the ovary to the fallopian tube. This shift is the result of work in BRCA1 and BRCA2 mutation carriers, who are at greatly elevated risk for high-grade serous carcinoma arising in the ovary, fallopian tube, or peritoneum.

Vol 20, No 3 (2013)

http://www.current-oncology.com/index.php/oncology/issue/current/showToc

Editorial 

Preventing ovarian cancer by salpingectomy 

W.D. Foulkes , MB BS PhD 

http://www.current-oncology.com/index.php/oncology/article/view/1613/1217

… The idea that the fallopian tube, and not the ovary itself, is the site of origin of most so-called ovarian carcinomas has gathered momentum over the last several years and has now reached a point at which clinicians and scientists are prepared to take action. The question is not whether clinical exploration of this conceptual change should proceed, but how to proceed. I do not believe that a trial is a feasible option, despite good intentions. But a prospective observational study, if conducted nationally (or, preferably, internationally), could answer the key questions discussed in the suite of articles presented here. I hope that the authors will start to plan such studies—in BRCA1 / 2 carriers and in the general population.

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Commentary 

Salpingectomy to prevent ovarian cancer 

A Countercurrents Series

S.A. Narod , MD

http://www.current-oncology.com/index.php/oncology/article/view/1471/1219

… In conclusion, I think that the proposal for preventing ovarian cancer through salpingectomy is a good one, but that the research agenda needs to be thought through. Different issues arise for women at average risk and for women with BRCA mutations; however, in both cases, a prospective cohort study of women who are having the operation is the most promising approach. If women are already having these operations, it would be a missed opportunity not to capture the relevant information for future review. One thing is for sure: If we wait until we have the evidence before we offer the operation (as several of Feyerman’s interviewees soberly opine), then we will never have the evidence.

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Editorial 

Opportunistic salpingectomy: the way forward—response to Steven Narod 

D.M. Miller , MD * , J.N. McAlpine , MD * , C.B. Gilks , MD * , D.G. Huntsman , MD *

http://www.current-oncology.com/index.php/oncology/article/view/1492/1218

…By all accounts, the uptake of salpingectomy with hysterectomy in our province has been excellent. We are collecting data on potential morbidity (so far, increased risk has not been measurable)a, and we will be monitoring our provincial cohort closely. Fortunately, it is possible to use the Canadian Institute for Health Information national databases to differentiate between the procedures performed: for example, salpingectomy versus tubal ligation for permanent sterilization, and hysterectomy with salpingectomy versus hysterectomy with salpingo-oophorectomy. We have already been able to show an impressive increase in salpingectomy in the province of British Columbia.

We strongly agree with Dr. Narod that

  • this cancer risk-reduction strategy is low-risk, and yet it is not supported by level 1 evidence.
  • conservative estimates of the risk–benefit ratio and the length of time required to see benefit suggest that the most practical and ethical way forward is to proceed with the proviso that this strategy is described as having “potential” rather than “proven” benefit.
  • given that we have proceeded without level 1 evidence, it is absolutely imperative that the impact be studied in a robust fashion.

This undertaking will require long-term effort. Because most tubal surgery for contraception and hysterectomies takes place in younger premenopausal women, we project that it might take up to 20 years to potentially realize a change in the incidence of ovarian cancer or a change in the distribution of histologic subtypes of ovarian cancer in British Columbia. However, that long view should not deter us from the endeavor. Also, by combining our efforts with other population-based programs, we can increase the power to detect changes in cancer risk earlier. We would welcome other jurisdictions coming on board with this program.

Commentary 

Fallopian tube removal: “STIC-ing” it to ovarian cancer: what is the utility of prophylactic tubal removal? 

T.J. Herzog , MD * , H.E. Dinkelspiel , MD *

http://www.current-oncology.com/index.php/oncology/article/view/1548/1220

…SHOULD BILATERAL SALPINGECTOMY WITH OVARIAN RETENTION BE THE NEW STANDARD FOR OVARIAN CANCER RISK REDUCTION? 

Certainly the case can be made for bilateral salpingectomy with ovarian retention (BSOR), considering the substantial reduction in projected tumour incidence. Greene and colleagues proposed that BSOR be performed for patients with BRCA mutations, because that intervention likely reduces the cancer incidence, but does not confer the negative consequences of oophorectomy, especially in premenopausal patients. Kwon et al. reported improved quality-adjusted life expectancy with salpingectomy followed by delayed oophorectomy for risk reduction in patients with BRCA mutations. The procedure also showed favorable cost effectiveness, making offering it a reasonable alternative to prophylactic bilateral salpingo-oophorectomy in patients who elect not to undergo bilateral salpingo-oophorectomy. The criteria could certainly be widened beyond just BRCA patients to the general population, but the potential negative effects would have to be considered. Table ii enumerates the relative risks and benefits of applying a bsor strategy. Clearly the most critical factor is a formal cost-effectiveness analysis. …

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Cancer System Indicator Snapshots 

Examining the use of salpingectomy with hysterectomy in Canada 

C. Sandoval , MSc * , M. Fung-Kee-Fung , MBBS MBA † , B. Gilks , MD ‡ , K.J. Murphy , MD § , R. Rahal , MBA * , H. Bryant , MD PhD * ||

http://www.current-oncology.com/index.php/oncology/article/view/1560/1233

… The present analysis examines the use of salpingectomy (surgical removal of the fallopian tubes) with hysterectomy in Canada. Identifying recent use of salpingectomy with hysterectomy across various jurisdictions will help to assess the impact over time of pursuing this emerging hypothesis and whether practice patterns are changing. …

… Further investigation into the use of salpingectomy as a prophylactic procedure for ovarian cancer is required. The present analysis provides a first look at the extent that salpingectomy with hysterectomy is being used in Canada, and if forms the background for future research studies. Other analyses, including looking at differences by income, urban or rural status, and hospital type, and examining complications in women undergoing the procedure, are underway. Continued monitoring of rates of salpingectomy with hysterectomy, together with ovarian cancer incidence and mortality over time, can also help to assess the effect of this intervention and whether its propagation is warranted.

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