COMMENTARY

Do Tubal Ligation and Salpingectomy Protect Against Ovarian Cancer?

Peter Kovacs, MD, PhD

Disclosures

June 22, 2015

Tubal Ligation and Salpingectomy and the Risk of Epithelial Ovarian Cancer and Borderline Ovarian Tumors: A Nationwide Case-Control Study

Madsen C, Baandrup L, Dehlendorff C, Kjaer SK
Acta Obstet Gynecol Scand. 2015;94:86-94

Background

The lifetime risk of being diagnosed with ovarian cancer is between 1% and 2%.[1] Because there are no good screening tests and the early disease is associated with nonspecific vague symptoms, most ovarian cancers are diagnosed at an advanced stage.

Certain reproductive factors and genetic mutations are associated with increased risk.[2] There are various histologic subtypes (serous, mucinous, endometrioid, clear cell, and other less common types). The various types may have different etiologies. For example, each ovulation induces a surface trauma in the ovary. Malfunction during the repair may result in mutations that could lead to cancer formation. The gonadotropin theory attributes a role to elevated levels of gonadotropins during the induction of malignant transformation. Androgens may also play a role in the initiation of malignant changes. Inflammatory reaction in response to the ascent of infectious or inflammatory agents through the reproductive tract has also been considered as a causative factor.[3]

It is also possible that cancer originally develops in adjacent organs and spreads to the ovary, causing its malignant changes. It has been proposed that some of the ovarian cancers (mostly the serous type) originate from the tube primarily.[4] This latter mechanism and the association between ascending infectious or inflammatory agents and ovarian cancer have led to an increased interest in the potential benefits of tubal occlusion or removal as a measure to prevent ovarian cancer.[5]

This large case-control study assessed the potential beneficial effects of tubal ligation and salpingectomy on ovarian cancer risk.

Data on patient characteristics, morbidity/mortality, medication use, and surgical procedures were collected from various Danish registers. Cases were women between the ages of 30 and 84 years with the first diagnosis of epithelial ovarian cancer or borderline ovarian tumors. For each case, 15 age-matched controls with no history of cancer were selected. Those with previous oophorectomy or salpingo-oophorectomy were not eligible to be controls.

During the analysis, an association between tubal ligation and salpingectomy and epithelial ovarian cancer was explored. The analysis was performed for various histologic subtypes. Age, parity, infertility, endometriosis, pelvic inflammatory disease, and hysterectomy were controlled for.

Researchers identified 13,241 women with ovarian cancer. Over 80% of the malignancies were diagnosed after the age of 50 years. Close to half of the cancers were serous epithelial cancers. Those diagnosed with cancer were more likely to be nulliparous and were less likely to have undergone a tubal ligation.

Borderline cancer was found in 3605 women. Close to half of the cases were diagnosed before the age of 50 years. Serous and mucinous subtypes were equally common. History of tubal ligation occurred with similar frequency among controls and cases.

The risk for epithelial ovarian cancer was less common in women with a history of tubal ligation (odds ratio [OR]: 0.87; 95% confidence interval [CI]: 0.78-0.98). The risk reduction was most pronounced for endometrioid cancer. Ovarian cancer risk did not vary with time since tubal ligation. The risk for ovarian cancer was reduced by almost half among those with a history of bilateral salpingectomy (OR: 0.58; 95% CI: 0.36-0.95). Tubal ligation had no impact on the risk for borderline ovarian cancer.

Viewpoint

The authors of this case-control study have found a significantly lower risk for ovarian cancer among those with tubal ligation or bilateral salpingectomy. The risk differed according to the histologic type.

The various mechanisms leading to the certain histologic types of ovarian cancer can explain the findings. With tubal disruption, endometrial cell, carcinogen chemicals, and infectious agents cannot reach the ovary. According to this study, the risk for endometrioid ovarian cancer was reduced by 50% among those who had tubal ligation before the age of 35 years.

Following tubal surgery, the blood flow from vessels that run from the uterus toward the ovaries is reduced; and, therefore, the amount of gonadotropins reaching the ovary and potentially inducing cancer is reduced as well. Likewise, the use of contraceptive pills has been shown to reduce the risk for ovarian cancer. This could be due to suppressed gonadotropin levels, lack of ovulation, and fewer infectious agents reaching the ovary.[6]

It is known that serous ovarian cancer often coexists with cancer of the fallopian tube or peritoneal cancer. This has raised suspicion that this type of ovarian cancer may originate in other organs and then spreads to the ovary. It has been shown that the removal of the tubes is associated with lower ovarian cancer (especially serous subtype) risk.[5,6] This finding was confirmed in this study too.

There is increasing evidence suggesting that certain measures can reduce ovarian cancer risk and should be discussed with patients. Those at high risk for ovarian cancer (mutation carriers, family history) should consider the prophylactic removal of not just the ovary but the tube as well once childbearing has been completed. Women who desire permanent sterilization could also elect to undergo salpingectomy instead of tubal ligation. The somewhat higher morbidity and the impact of surgery on ovarian function need to be considered, however.

Future studies should further explore the benefits of tubal ligation or salpingectomy as preventive measures against ovarian cancer. Until we have better screening tools that could allow us to diagnose the disease at an early, treatable stage, we need to consider other preventive measures to avoid a rather poor prognosis.

Abstract

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