For Health Professionals

Advocating Fallopian Tube removal at the time of hysterectomy to prevent ovarian cancer

Dr. Sarah Finlayson, FRCSC, OVCARE gynaecologic surgeon and spokesperson for local and international knowledge translation initiatives, VGH & BCCA

What I did before
When I was in training as a gynecologic surgeon, I was taught how to do a hysterectomy and tubal ligation. I practiced until I had mastered it. By surgical convention, when we did a hysterectomy and planned to leave the ovaries in situ (in pre-menopausal women) we left the fallopian tubes inside the patient too. At the time of tubal ligation, we clipped or burned the tubes and left them inside the patient.

What changed my practice
High grade serous cancer of the ovary represents about 2/3rds of the cases of ovarian cancer that we see. These cancers are often diagnosed at an advanced stage. While this cancer usually responds to initial treatment, it frequently recurs and is not curable in the majority of patients. A growing body of knowledge reveals that the majority of high grade serous “ovarian” cancers are actually fallopian tube cancers. The precursor lesions begin in the fimbriated end of the fallopian tube and the cancer spreads from there. This knowledge about the true origin of this devastating cancer completely changed my surgical practice.

What I do now
I now advise patients to consider removing their fallopian tubes at every single hysterectomy—and to discuss this with their gynecologist. Family Physicians can advocate for their patients to ensure the fallopian tube is removed at hysterectomy and tubal ligation. My hope is that removing the fallopian tubes will prevent many cases of this terrible disease. As a gynecologic oncologist, the majority of my patients already have cancer. The potential for a major impact in ovarian cancer prevention rests with general gynecologists—who perform the vast majority of hysterectomies and tubal ligations. Hysterectomy and tubal ligation are among the most common surgeries that a woman will undergo in her lifetime. In September 2010, the Ovarian Cancer Research Program of BC, launched a province-wide educational initiative aimed at every gynecologist in BC. We asked gynecologists to consider removing the fallopian tubes at hysterectomy and at tubal ligation (when a patient requests permanent contraception). I believe these simple changes in surgical convention hold the promise of preventing future cases of “ovarian cancer”.

The Society of Gynecologic Oncology of Canada (GOC) supports OVCARE’s cancer prevention strategy.
In September 2011, the GOC endorsed OVCARE’s cancer prevention strategy by issuing a statement recommending that “physicians discuss the risks and benefits of bilateral salpingectomy with patients undergoing hysterectomy or requesting permanent, irreversible contraception,” and that an “ovarian cancer prevention (research) study focused on fallopian tube removal is a GOC priority.”  www.g-o-c.org

View educational videos to learn the science behind our understanding of the fallopian tube as a precursor to “ovarian cancer”.

Recommendations to all gynecologists

  1. Remove the fallopian tubes of women in the general population along with fimbriated end at the time of hysterectomy.
  2. Performing salpingectomy in place of tubal ligation.
  3. Referral of all women with high-grade serous cancer to undergo genetic counseling and BRCA mutation screening. Risk-reducing interventions could be undertaken in family members found to have a mutation. Visit the BCCA Hereditary Cancer Program site for more information.

References: (Note: Article requests require a login ID with the BC College of Physicians website or with UBC)

1. Tone AA, Salvador S, Finlayson SJ, Tinker AV, Kwong JS, Lee C-H, et al. The role of the fallopian tube in ovarian cancer. Clin Adv Hematol Oncol. 2012 May; 10(5): 296-306 

2. Tone AA, Huntsman DG, Miller DM. Screening of symptomatic women for ovarian cancer . The Lancet Oncology. 2012 April; 13(4):e137-e138 

3. Przybycin CG, Kurman RJ, Ronnett BM, Shih IM, Vang R. Are All Pelvic (Nonuterine) Serous Carcinomas of Tubal Origin?Am J Surg Pathol. 2010 2010 October; 34(10): 1407-16. (View article with CPSBC or UBC)

4. Salvador S, Gilks B, Köbel M , Huntsman D, Rosen B, Miller D. The fallopian tube: primary site of most pelvic high-grade serous carcinomas. Int J Gynecol Ca 2009;19:58-64 (View article with CPSBC or UBC)

5. Crum CP, Drapkin R, Miron A, Ince TA, Muto M, Kindelberger DW, et al. The distal fallopian tube: a new model for pelvic serous carcinogenesis. Curr Opin Obstet Gynecol 2007;19(1):3-9. (View article with CPSBC or UBC)

6. Kindelberger DW, Lee Y, Miron A, Hirsch MS, Feltmate C, Medeiros F, et al. Intraepithelial carcinoma of the fimbria and pelvic serous carcinoma: Evidence for a causal relationship. Am J Surg Pathol 2007;31(2):161-9. (View article with CPSBC or UBC)

7. Lee Y, Miron A, Drapkin R, Nucci MR, Medeiros F, Saleemuddin A, et al. A candidate precursor to serous carcinoma that originates in the distal fallopian tube. J Pathol 2007;211(1):26-35. (View article with CPSBC or UBC)

8. Crum CP, Drapkin R, Kindelberger D, Medeiros F, Miron A, Lee Y. Lessons from BRCA: the tubal fimbria emerges as an origin for pelvic serous cancer. Clin Med Res 2007;5(1):35-44. (View article with CPSBC or UBC)

 

 

Partners:

BC Cancer Agency Vancouver Coastal Health UBC Faculty of Medicine BC Cancer Foundation VGH/UBC