FALLOPIAN TUBE REMOVAL FOR OVARIAN CANCER PREVENTION: BENEFITS, RISKS AND RECOVERY

In the field of cancer medicine, the prevailing wisdom is that early detection and diagnosis saves lives. Catching cancer at earlier stages generally improves patient outcomes and increases chances of survival. When cancers are detected in more advanced stages, they have often progressed or spread to other areas of the body, making the cancer harder to eradicate.

For breast cancer, routine mammograms, at-home breast exams and clinical breast exams have proven to be effective, life-saving measures for detecting breast cancer early. For colorectal cancer, regular colonoscopies and at-home screening kits can detect precancerous polyps before they become invasive cancer.

However, for ovarian cancer, there is currently no effective way to screen for early stages of the disease, making prevention all the more important.

In January 2023, the Ovarian Cancer Research Alliance proposed a relatively new strategy to prevent ovarian cancer: fallopian tube removal.

The organization’s recommendation echoes the message from a growing number of gynecologic oncology experts who are beating the drum for this procedure.

But why remove the fallopian tubes to prevent ovarian cancer? While one might assume that ovarian cancer originates in the ovaries, as its name suggests, the disease is a bit of a misnomer in some cases. Emerging research from the past few decades has shown that the most common subtype of ovarian cancer – high-grade serous carcinoma, or HGSC – frequently starts in the fallopian tubes.

Also referred to as an opportunistic salpingectomy, fallopian tube removal can significantly reduce the risk of ovarian cancer in people who do not carry genetic mutations for the disease, including BRCA1, BRCA2, RAD51 and KRAS.

“We know that only 20% of ovarian cancers are due to an inherited risk,” says Dr. Karen H. Lu, professor and chair of gynecologic oncology and reproductive medicine at the University of Texas MD Anderson Cancer Center in Houston. “For the other 80%, opportunistic salpingectomy is something that they can do to be proactive.”

Why Is Prevention Important?

Although ovarian cancer is rare – you have a 1.3% chance of developing the disease in your lifetime – it is the fifth leading cause of cancer deaths in women and people with ovaries, according to the American Cancer Society. It has the highest mortality rate of any other gynecological cancer, including cervical cancer, uterine cancer and vaginal cancer, as surgery and chemotherapy do not always provide a curative outcome.

The American Cancer Society estimates that approximately 19,710 women will be diagnosed with ovarian cancer and about 13,270 women will die from the disease in 2023. While ovarian cancer mortality has steadily declined over the past two decades as a result of lower incidence and better treatment, detecting early-stage ovarian cancer remains an elusive task. To date, there have not been any successful screening tests.

In a large 2021 clinical trial published in the Lancet, researchers in the United Kingdom enrolled 202,562 women who were at average risk of developing ovarian cancer to evaluate the effectiveness of screening methods for the disease. Using a blood test to detect biomarker CA-125 and ultrasound imaging, researchers were able to diagnose cases of ovarian cancer in stage 1 or stage 2, an estimated 18 months before symptoms presented. However, this large study showed no improvement in survival in the screening group at a median follow-up of 16.3 years despite detecting the disease at earlier stages.

“That (study) provided very compelling reasons to look at the other side of early detection, which is prevention,” Lu says. “They go hand in hand.”

What Are the Symptoms of Ovarian Cancer?

Unfortunately, ovarian cancer is a stealthy disease that is hard to detect in its early stages. It typically doesn’t cause the hallmark symptoms of gynecological cancers, such as bleeding, vaginal discharge, fever or pain. Because the normal female pelvis is a large structure, tumors that develop at the end of the fallopian tube can easily shed and spread in the pelvis and the lining of the abdomen, hiding in the region undetected until they become more advanced.

“(The tumors) are a little bit subtle in their symptoms until they become large enough or spread quite a bit in the pelvis and in the abdomen to give the patients the more concerning symptoms,” explains Dr. Nadeem Abu-Rustum, chief of gynecologic service and Avon chair in gynecologic oncology research at Memorial Sloan Kettering Cancer Center in New York City. “By that time, it’s already at stage 3 or stage 4.”

The most common symptoms of ovarian cancer include:

Bloating.
Abdominal pain.
Appetite changes, such as feeling full early after a meal.
Urinary changes, such as urgency and frequency.

“Prevention for women is very challenging for ovarian cancer, and this is where we make it a high priority to really educate women about listening to their bodies,” says Dr. Kristina A. Butler, a gynecologic oncologist at Mayo Clinic Comprehensive Cancer Center in Phoenix. “These women with a cancer diagnosis often have these symptoms 20 to 30 times per month compared to women who don’t have a cancer diagnosis.”

What Is Fallopian Tube Removal?

Fallopian tube removal is the procedure in which doctors surgically remove the fallopian tube in women or people born with ovaries who are already undergoing surgery in the pelvic region – such as a hysterectomy, tubal ligation, cyst or fibroid removal or endometriosis surgery – and don’t plan to have any more children.

Fallopian tube removal is most commonly performed as a minimally invasive procedure using laparoscopic or robotic surgery but can be done during open or transvaginal surgery, depending on the primary reason for the surgery.

“Anytime someone is undergoing a pelvic procedure, like a hysterectomy or other pelvic procedures related to pelvic structures, the tube and ovary are usually easily seen,” Abu-Rustum explains. “It's a straightforward procedure.”

To be clear, experts are not encouraging people at average risk to undergo this procedure if they are not already planning to have surgery in the pelvic region for other indications.

“We definitely don’t want women to call and say, ‘I want to have surgery for this,’ but it’s that concept of opportunism,” Lu says. “If you’re having surgery anyway, it’s something you should consider.”

What Are the Benefits of Fallopian Tube Removal?

The primary benefit of fallopian tube removal is that it significantly reduces the risk of ovarian cancer.

In a landmark study published in JAMA Network Open in February 2022, researchers evaluated whether opportunistic salpingectomy was an effective strategy for preventing ovarian cancer. After comparing data from 25,889 individuals who had their fallopian tubes removed from 2008 to 2017 to a control group of 32,080 people who underwent either a hysterectomy or tubal ligation, researchers found dramatically fewer numbers of ovarian cancer than expected in the cohort that had an opportunistic salpingectomy.

The results of the study showed that there were zero cases of serous ovarian cancer in patients who had their fallopian tubes removed, while there were 15 serous cancers that arose in the control group. The study’s findings provide compelling evidence that fallopian tube removal is a safe and effective way to prevent ovarian cancer from developing.

“As someone who has spent over 20 years working on early detection and prevention, I’m really excited about the momentum that is building and the opportunity for women to have this knowledge and act on it,” Lu says.

Another benefit of the procedure is that it spares the ovaries, which play a vital role in women’s overall health.

The ovaries produce estrogen and progesterone hormones that are essential to:

For decades, removing the almond-sized organs – a procedure known as prophylactic oophorectomy – was the gold standard for preventing ovarian cancer. However, mounting evidence has shown that removing the ovaries causes premature menopause in people and is associated with deleterious health effects, including:

Genital tissue atrophy.
Bone loss.
Heart disease.
Increased mortality.
Reduced quality of life.

“(Removing the ovaries) subjects a woman to be thrust into menopause and has a multitude of symptoms associated with it that can be adverse,” says Butler, who is involved in an ongoing clinical trial at Mayo Clinic that confirms removing the fallopian tube is a safe alternative to reducing ovarian cancer risk without removing the ovaries.

In addition, removing the ovaries is associated with an increased risk of female sexual dysfunction, anxiety and depression.

“The ovary is an incredibly important organ. Every effort should be made to keep a healthy ovary that does not need to be removed where it is,” Abu-Rustum says. “Even though (patients) may not be actively trying to have children, keeping the ovary is extremely important for their well-being.”

What Are the Risks of Fallopian Tube Removal?

Opportunistic salpingectomy is a safe procedure, with relatively little risk associated with it, especially when performed using minimally invasive techniques. The procedure has not been shown to increase the risk of complications – such as bleeding, infections or fever – or affect ovarian function, Abu-Rustum explains.

In fact, opportunistic salpingectomy’s track record of safety and efficacy is backed not only by the Ovarian Cancer Research Alliance, but also by the American College of Obstetricians and Gynecologists and the Society of Gynecologic Oncology, two major medical organizations in the field.

“If you're having surgery anyway for another gynecologic disorder – be it fibroids, endometriosis or prolapse – please be advocates for yourself in removing the fallopian tube because this will not add additional impact to you with any hormonal status changes because the ovaries are kept safe," Butler says.

What Is the Recovery Process?

Because fallopian tube removal is most commonly performed laparoscopically, which typically only requires three small incisions approximately 0.4 to 0.6 inches in length, the recovery is usually one to three weeks, according to Johns Hopkins Medicine.

In addition, removing the fallopian tubes does not significantly prolong the typical recovery time for the primary surgery.

“It's very simple during vaginal or laparoscopic hysterectomy to also remove the fallopian tubes very safely,” Butler says. “The recovery would be very similar. It's almost negligible for the added procedure.”

Ultimately, given how safe and effective fallopian tube removal is in protecting people from ovarian cancer, gynecologic experts are encouraging people to consider the procedure if they plan to undergo pelvic surgery.

"This is such a great opportunity to make a difference in the survival for women," Butler says.

For those who are not planning a pelvic procedure, health experts encourage people to know their risk of ovarian cancer by finding out if they have a family history of cancer and getting genetic testing done.

"I would encourage women to have this discussion with their OB-GYN," Abu-Rustum says. "This combination of doing genetic testing and talking about opportunistic salpingectomy may give us significant change over the next 10 to 20 years."

2023-03-31T17:20:21Z dg43tfdfdgfd