Ovarian Cancer Prevention With the Opportunistic Salpingectomy: An Opportunity for Multidisciplinary Collaboration

Ryan M. Kahn, MD

Over the past 2 decades, we have learned that a majority of what is thought to be high-grade serous ovarian cancer in fact originates in the fimbriated end of the fallopian tube. Data from multiple studies have shown that the outer cells of the distal fallopian tube are transformed into malignant cells and subsequently spread to the neighboring ovary.^1,2 This implies that surgical removal of the fallopian tubes may prevent certain types of ovarian cancer.

Our new understanding of the pathogenesis has given rise to a promising prevention strategy for women at an average risk of developing ovarian cancer through surgical removal of the fallopian tubes, referred to as an opportunistic salpingectomy (OS).

OS refers to the removal of fallopian tubes instead of tubal ligation, or during hysterectomy, while leaving the ovaries intact. Study findings suggest that OS is associated with an ovarian cancer risk reduction approaching 80%.³ Recent findings from 1 of the largest cohort studies conducted to date show that none of the 25,000 women in the study’s OS cohort developed a serous ovarian cancer throughout the duration of the study.⁴ Additional data have demonstrated that OS is safe and cost-effective and has not shown indications of an earlier age of onset of menopause.^5-7

With the hope of expanding the surgery to even more women across the population who have completed childbearing, investigators have moved to assess the efficacy of OS during nongynecologic surgeries, such as during removal of the appendix or gallbladder, colorectal surgery, hernia repair, and others. This opens a window of opportunity for hundreds of thousands of women undergoing these procedures annually.³

A prospective European feasibility study of 105 women investigating OS during elective cholecystectomy found that surgeons performed the procedure successfully in 93% of cases. The median additional operating time was 13 minutes (range, 4-45).⁸ A cost- analysis study looking at qualityadjusted life years has suggested that OS during nongynecologic surgeries can be a cost-effective strategy to prevent ovarian cancer among average-risk women.⁷

The Markov Monte Carlo simulation model by Kwon et al demonstrated OS with hysterectomy was less costly ($11,044.32 ± $1.56) than hysterectomy alone ($11,206.52 ± $29.81). Additionally, for surgical sterilization, OS was more cost-effective long term with an incremental ratio of $27,278 per year of life gained.⁷

Despite the projected cancer prevention and population health benefits of OS during nongynecologic surgeries, these results have been seldom reported and surgeons rarely conduct the procedure outside early studies as there are currently no guidelines to rely upon. It is imperative that we delve further into this novel prevention strategy with prospective trials. This will require buy-in, collaboration, and training from both general and gynecologic surgical teams. Cross-disciplinary efforts to garner more information regarding long-term effects and outcomes will be necessary before OS conducted during nongynecologic surgeries can become a standard recommendation for women who have completed childbearing.

If achieved, widespread implementation of OS holds the potential to reduce ovarian cancer mortality in the United States by 15%—the equivalent of thousands of lives saved.^9,10 Surgery has always been an all-encompassing team sport, requiring the collaboration of all teams involved to work toward improved outcomes for individual patients. OS now has the potential for surgical teams to join forces in the hopes of improving outcomes for women across the world.

The future widespread implementation of the OS serves as an opportunity for fellows across different surgical specialties—including but not limited to gynecologic, colorectal, general, urologic, and hepatobiliary—to collaborate. First, raising awareness regarding the potential of OS across different specialties is essential. Next steps will include expanding training during residency and fellowship across various disciplines, which will help with feasibility as well as future implementation. This will require both buy-in and teamwork from many to learn the OS procedure in a safe and effective manner.

Ryan M. Kahn, MD, is a gynecologic oncology fellow at Memorial Sloan Kettering Cancer Center in New York, NY.

Sushmita Gordhandas, MD, is a fellow in the Gynecologic Oncology Department of Surgery at Memorial Sloan Kettering Cancer Center in New York, NY.

References

1. Kindelberger DW, Lee Y, Miron A, et al. Intraepithelial carcinoma of the fimbria and pelvic serous carcinoma: evidence for a causal relationship. Am J Surg Pathol. 2007;31(2):169. doi:10.1097/01. pas.0000213335.40358.47
2. Kurman RJ, Shih IeM. The origin and pathogenesis of epithelial ovarian cancer: a proposed unifying theory. Am J Surg Pathol. 2010;34(3):433-443. doi:10.1097/PAS.0b013e3181cf3d79
3. Matsuo K, Chen L, Matsuzaki S, et al. Opportunistic salpingectomy at the time of laparoscopic cholecystectomy for ovarian cancer prevention: a cost-effectiveness analysis. Ann Surg. 2022;10.1097/ SLA.0000000000005374. doi:10.1097/SLA.0000000000005374
4. Hanley GE, Pearce CL, Talhouk A, et al. Outcomes from opportunistic salpingectomy for ovarian cancer prevention. JAMA Netw Open. 2022;5(2):e2147343. doi:10.1001/jamanetworkopen.2021.47343
5. McAlpine JN, Hanley GE, Woo MM, et al. Opportunistic salpingectomy: uptake, risks, and complications of a regional initiative for ovarian cancer prevention. Am J Obstet Gynecol. 2014;210(5):471. e1-11. doi:10.1016/j.ajog.2014.01.003
6. Hanley GE, Kwon JS, McAlpine JN, Huntsman DG, Finlayson SJ, Miller D. Examining indicators of early menopause following opportunistic salpingectomy: a cohort study from British Columbia, Canada. Am J Obstet Gynecol. 2020;223(2):221.e1-221.e11. doi:10.1016/j.ajog.2020.02.005
7. Kwon JS, McAlpine JN, Hanley GE, et al. Costs and benefits of opportunistic salpingectomy as an ovarian cancer prevention strategy. Obstet Gynecol. 2015;125(2):338-345. doi:10.1097/ AOG.0000000000000630
8. Tomasch G, Lemmerer, Oswald, et al. Prophylactic salpingectomy for prevention of ovarian cancer at the time of elective laparoscopic cholecystectomy. Br J Surg. 2020;107(5):519-524. doi:10.1002/ bjs.11419
9. Dilley SE, Havrilesky LJ, Bakkum-Gamez J, et al. Cost-effectiveness of opportunistic salpingectomy for ovarian cancer prevention. Gynecol Oncol. 2017;146(2):373-379. doi:10.1016/j. ygyno.2017.05.034
10. Hughes BN, Herzog HT, Brown J, Drury LK, Naumann RW. Opportunistic salpingectomy would significantly reduce ovarian cancer mortality and would reduce overall health care expenditures. Gynecol Oncol. 2019;153:e11. doi:10.1016/j.ygyno.2019.03.132