Routine Removal of Fallopian Tubes Urged to Reduce Risk for Ovarian Cancer

Roxanne Nelson

September 17, 2010

September 17, 2010 — Should the fallopian tubes be routinely removed when a hysterectomy or tubal ligation is performed?

Yes, according to gynecologic oncologists from the Ovarian Cancer Research Program at Vancouver General Hospital, in British Columbia, and the BC Cancer Agency. They have begun a campaign that urges their colleagues to routinely remove the fallopian tubes to prevent ovarian cancer.

This would be a change in the standard of practice; fallopian tubes are generally left in place during routine hysterectomies and tubal ligations. But there is considerable evidence, they say, supporting the theory that the fallopian tube mucosa might be the primary source of high-grade pelvic serous carcinoma in many, if not the majority, of cases.

The data were published in 2009 in the International Journal of Gynecological Cancer (2009;19:58-64).

Although this move will not eliminate all cases of ovarian cancer, it could reduce mortality from high-grade serous cancer by 30%, explained David Huntsman, MD, associate professor of pathology and laboratory medicine at the University of British Columbia, and one of the coauthors of the paper.

"The cancers would never happen, we wouldn't be seeing the patients in the clinics," he said in an interview. "This could have widespread implications."

However, one expert approached by Medscape Medical News for independent comment wondered if it is too early for a practice change.

This recommendation is based on a theory that is quite provocative but is not yet proven.

"This recommendation is based on a theory that is quite provocative but is not yet proven," said Stephanie V. Blank, MD, assistant professor in the Division of Gynecologic Oncology at New York University School of Medicine in New York City. "Still, if this is true, and while doing another surgery we have an opportunity to prevent ovarian cancer without compromising ovarian function, incidental salpingectomy merits consideration."

But as far as mandating incidental salpingectomy, "we aren't there yet," she added.

Dr. Blank agreed that there is no real downside to removing the fallopian tubes during routine procedures.

"Among women having hysterectomies who wish to retain their ovaries — the tubes are usually left in as well," she said. "But if ovaries are removed for risk reduction, tubes are routinely removed along with the ovaries."

However, she pointed out that removing the tubes and leaving the ovaries could have more of a surgical risk. The procedure is potentially more technically difficult.

Circumstantial but Compelling

The reason fallopian tubes are not removed at the time of hysterectomy is that there hasn't been any reason to do so, Dr. Huntsman pointed out. "But now we have a good reason — there is no downside and there is an upside as it may prevent cancer. I believe that it will be adopted widely."

The supporting data are currently circumstantial, but should be considered compelling, he added. "I think it is compelling enough to say that the majority of cancers arise directly or indirectly from the fallopian tubes."

But even if this change in procedure is implicated, the results will not be immediately seen. "We believe that as we study this cancer in the years to come, we will see decreasing numbers of cases," said Dr. Huntsman, who is also director and a cofounder of OvCaRe, a multidisciplinary, multi-institutional ovarian cancer research team in Vancouver. "We're thinking [that in] 8 to 10 years, if there is a very rapid uptake, we should begin to see an effect."

Coauthor Sarah Finlayson, MD, a gynecologic oncologist from the Ovarian Cancer Research Program and assistant professor of medicine at the University of British Columbia, emphasized the need to educate physicians outside the cancer community.

"Routine hysterectomies and tubal ligations are performed by gynecologists in the community," she told Medscape Medical News. "These are not cancer patients."

Dr. Finlayson is leading the education outreach program that is being directed to all gynecologists in the province. The Ovarian Cancer Research Program is working with Ovarian Cancer Canada and other organizations to help disseminate the information across Canada.

"During the past 5 years, there have been a number of researchers looking into the origins of ovarian cancer," said Dr. Finlayson. "Most ovarian cancers are of the serous type, and the origins of most of these cancers are in the fallopian tubes."

The campaign to change practice is just getting off the ground, but according to Dr. Finlayson, the response has been positive. "We are hoping that this will become a national strategy in the coming years."

Originates in the Fallopian Tubes

The 2009 paper, from which this recommendation was derived, was a review of the evidence suggesting that pelvic serous carcinoma originates in the fallopian tubes. The analysis put forward a theory that "inflammation in the tube, caused by menstrual cytokines or infection, is critical to the genesis of these tumors."

The authors note that about 120,000 hysterectomies are performed each year in Canada and more than 617,000 procedures are performed in the United States. At the BC Cancer Agency, 18.7% of women diagnosed with ovarian cancer have undergone antecedent hysterectomy.

If this hypothesis is correct, they write, many of these could have been prevented by removing the fallopian tubes at the time of the hysterectomy. Removal of the fallopian tubes would require only a "minor change in surgical technique and has at least the potential to prevent a significant number of high-grade serous tumors with no increase in surgical morbidity," the authors write.

No Significant Downside, Not Ready for Mandate

"There are no significant downsides to removing the fallopian tubes if the patient has completed childbearing," said Diane Yamada, MD, associate professor in the Department of Obstetrics and Gynecology at the University of Chicago in Illinois.

"There is the potential risk of having some bleeding when the tubes are removed that might require the ovary to be removed, but this shouldn't be common," said Dr. Yamada, who was approached by Medscape Medical News for independent comment. "The surgery might be ever so slightly longer because of the time it takes to remove the tubes separately, but this would be an anesthetic issue."

A technical issue is to make sure the surgeon removes as much of the tube as possible so the patient doesn't get a hydrosalpinx — a collection of fluid in a remaining portion of the tube — which could cause some pain, she noted. "But, again, this should not be common."

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