Season 2 Episode 9: Opportunistic Salpingectomy as a Method of Ovarian Cancer Prevention

We are back with another bonus episode of the GOSH Podcast!

At the beginning of February 2022, Dr. Gillian Hanley and her team published their preliminary research findings that suggest removing a woman’s fallopian tubes at the time of other routine gynecologic surgeries is a safe, effective way to reduce ovarian cancer risk for women. Through the support of OVCARE, Vancouver Coastal Health, Vancouver Coastal Health Research Institute, BC Cancer, BC Cancer Foundation, VGH & UBC Hospital Foundation, and the UBC Faculty of Medicine, these findings are a huge step towards learning more about ovarian cancer prevention.

You can read the publication here: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2788855
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Transcript

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Stephanie  00:01 

Thanks for listening to the GOSH podcast. GOSH stands for the Gynecologic Oncology Sharing Hub, an open space for real and evidence based discussions on gynecologic cancers. We'll share the stories of gyne cancer patients and survivors and hear from researchers and clinicians who are working behind the scenes to improve the lives of people with gynecologic cancers. Our podcast is produced and recorded on a traditional unceded territories of the Musqueam, Squamish, and Tsleil-Waututh Nations. It is produced by the Gynecologic Cancer Initiative, a province wide initiative in British Columbia with a mission to accelerate transformative research and translational practice on the prevention, detection, treatment and survivorship of gynecologic cancers. Hi, I'm Nicole Keay, and I'm Stephanie Lam and you're listening to the GOSH, podcast. Okay, so welcome back to an episode of the GOSH, podcast. So on the last season, we talked to Dr. Gillian Hanley about ovarian cancer prevention in British Columbia, and around the world. So that was season one, episode five. So if you're interested in learning more about that episode, definitely go check it out. So in that episode, she talked about ovarian cancer prevention. And the campaign that was started in BC in 2010, that centered around a procedure called opportunistic salpingectomy. So we're very excited to have Dr. Hanley come back onto the podcast to talk more about opportunistic salpingectomy, and share some of the emerging and exciting work that was just published a few days ago, looking at the outcomes of this procedure, and what that means on ovarian cancer prevention. So Nicole, would you like to get started?  

Nicole  01:50 

Yeah, absolutely. So Dr. Gillian Hanley is an assistant professor in the Department of OBGYN at the University of British Columbia. She's a newly appointed Canada Research Chair in population based gynecologic and perinatal outcomes, and she has played an important role in researching ovarian cancer prevention strategies. Welcome back to the podcast, Dr. Hanley.  

Gillian  02:15 

Thank you. Thanks for having me, Stephanie Nicole.  

Nicole  02:19 

Alright, so Stephanie mentioned that we talked to you in our last season. But for our listeners, maybe you could just remind us again, what opportunistic salpingectomy. 

Gillian  02:32 

Yeah, so um, about 15 or 20 years ago now, there was scientific evidence that suggested that the tissue of origin for most high grade serous ovarian cancers, which is the most common and the most lethal type of ovarian cancer is actually not on the ovarian surface, which is what was originally believed. So there was some evidence that that came to light suggesting that it was likely the fallopian tube, not the ovary that was the tissue of origin for these really awful, really deadly ovarian cancers. And with that, finding came prevention opportunity, because the fallopian tube plays no known role post childbearing. So the fallopian tube is integral for, you know, ensuring that the egg can get from the ovary to the uterus and so plays a really important role in pregnancy and fertilization but no known role once a person is done with childbearing no longer wants to have any future pregnancies. And so, some of the very smart OBGYNs and gynecologic oncologists in British Columbia realized that we had an opportunity to possibly prevent future ovarian cancers by removing fallopian tubes in people who were undergoing surgeries to have other you know, for other gynecologic conditions. So, they recommended specifically that at the time of hysterectomy, which is removal of the uterus that fallopian tubes be removed at the same time. Prior to this recommendation, they were just left in situ in people who were retaining their ovaries. And for people who were looking for permanent tubal sterilization, which is commonly referred to as having your tubes tied instead instead of ligating those tubes, which is basically just cauterizing them so that the egg can no longer move from the ovary to the uterus. Rather than doing that the two would be entirely removed. And so that's what we're talking about when we talk about opportunistic salpingectomy. Salpingectomye is the medical term for fallopian tube removal. And we call it opportunistic because we're doing it in people, where we're already doing another surgery in the pelvis and the tubes are accessible and available, so we have an opportunity to remove them. And before we did opportunities salpingectomy, we would have just left them. But now that we know that they are likely the tissue of origin for these high grade serous ovarian cancers, we are taking them out at that time instead of leaving them in place. And just to clarify, um, you know, the reason that we don't take ovaries out to prevent ovarian cancer is that if we remove ovaries in women under age 50, we put them automatically into premature surgical menopause, which has not only, you know, quite devastating short term consequences in terms of, you know, vasomotor symptoms, sleep disturbances, decreased quality of life, sexual health issues, but also puts them at increased risk for long term adverse events, including increasing their risk for cardiovascular disease, and osteoporosis and bone fractures. So we don't want to take ovaries out to prevent ovarian cancer, because we will likely do more harm than good. So knowing that we can take tubes out and not, you know, do that harm that we would do by removing ovaries, but also possibly prevent these really awful ovarian cancers was, you know, a great finding. And so in British Columbia, even though we didn't yet have the evidence, knowing that it was effective. We started to do this in September of 2010, when Diane Miller and others at OVCARE lead this educational campaign. 

Stephanie  07:10 

Great. Thanks, Gillian. So it's been, I guess, 12 years now since 2010, and the launch of that campaign, and on the last episode, you talked a lot about kind of the safety of this procedure and what that meant for patients who were undergoing opportunistic salpingectomy. So now you have this really exciting publication that has come out recently. Can you just go over some of the key findings from this work?  

Gillian  07:38 

Yeah, so um, we were looking at follow up data from people in British Columbia who've had opportunistic salpingectomy and people who've had what I'm going to refer to as the control surgeries, which are hysterectomy alone, or tubal ligation. And the reason I'm calling these the control surgeries is because these are the surgeries that people would have received prior to the recommendation that they undergo opportunistic salpingectomy. And so that's who we compare our opportunistic self inject me group to because they're the most similar group of patients to make this comparison with. And we also know that hysterectomies and Tubal ligation are procedures that themselves influence risk for ovarian cancer. So we want to make make the comparison to an appropriate group. So those are our control group. And so what we found in this paper is that we looked at everybody in British Columbia who had undergone either an opportunistic salpingectomy or one of these control surgeries, and we followed them out as long as our data would permit. And our data were till the end of calendar year of 2017, for this paper, and we looked at all of the ovarian cancers that arose in these groups. And we asked how many we would have expected in the opportunistic salpingectomy group if cancers were arising at the same rate based on the age and the follow up time in that group, as they were arising in our control groups, so we calculated an expected number of ovarian cancers that we would have predicted that we would have seen where there are no differences in the ovarian cancer rates between the opportunistic salpingectomy group and the control group. And then we compare that with the number that we actually observed. And what we found was that for the opportunistic salpingectomy group, we did not observe a single high grade serous ovarian cancer in any of those people. And if cancers, high grade serous ovarian cancers had been arising at the same rates as as they arose in that control group, we should have seen five of those. And so another thing that we do often in research is we calculate 95% confidence intervals, which tell us how likely it is that our finding was just due to chance. And if your your result falls outside of that 95% confidence interval, you can be more confident that it's not just due to chance. And we did in fact, that zero was below the low end of that 95% confidence interval, suggesting that it's due to the opportunistic salpingectomy, and not just random chance that we had lower rates in that group. And the same was true when we looked at all epithelial ovarian cancers. So we found significantly fewer than we would have expected in our opportunistic salpingectomy. And then we asked ourselves, you know, because we're dealing with some pretty low numbers here, these are, you know, preliminary signals of effectiveness. So we can't do all of the really fancy statistics that we would often do, because we have these small numbers. And so we asked ourselves, how do these groups look in terms of the well known risk and protective factors for ovarian cancer? Could they just differ in that, you know, the opportunities salpingectomy group just looks like they would generally be at lower risk for ovarian cancer, because they used a lot more oral contraceptive pills, or they had more babies or they were younger, or you know, any of these factors that we know influence risk for ovarian cancer. So we compare the group on those factors. And we actually found that the opportunistic salpingectomy group looked like they were at increased risk for ovarian cancer, if anything based on those factors, because they were older, and they had fewer live births and fewer previous pregnancies, which increasing number of births and an increasing number of pregnancies decreases your risk for ovarian cancer. So the fact that they had less would put them at a slightly increased risk compared to the control group. And they also had a much higher rate of endometriosis, which is also a risk factor for not high grade serous ovarian cancer, but to other types of ovarian cancer. And so that would suggest that that that group was actually at a slightly increased risk for ovarian cancer compared to the control group. So we don't think that differences in those risk and protective factors can explain why we found that they had significantly fewer observed than expected than expected cancers. And so then we thought, Oh, well, could this possibly be explained just by other general lifestyle factors? Is this a group of patients who is you know, more proactive when it comes to their health? You know, are they just generally at decreased risk for cancer for whatever reason that we can't measure in our data? And so to try to answer that question, we looked at rates observed and expected numbers of breast and colorectal cancers, we did the exact same thing that we did for ovarian cancers, where we predicted the expected number using the rates in the control group, and then compared it to the number that we actually observed in our opportunistic salpingectomy group, and, you know, we would have expected 22.1 breast cancers, and we observed 23. So they were bang on. And then we would have predicted 9.3, we would have expected like 9.3 colorectal cancers, and we observed eight, so there was no difference in those other cancers. They looked exactly, the groups were exactly comparable. So if we predicted how many we thought we would see based on our control group, it was almost exactly what we saw in our opportunistic salpingectomy group. So again, that suggests that, you know, what we saw with respect to the, the, you know, much significantly fewer observed cancers when we looked for high grade serous ovarian cancers and epithelial ovarian cancers cannot be explained by you know, general lifestyle factors or an overall reduced risk for cancer in that group. It really suggests that the opportunistic salpingectomy is what explains that reduced number of cancers that we're seeing in that group. So it's exciting. It's preliminary evidence that, you know, this intervention that, you know, we took a shot on back in 2010, is, in fact saving lives in British Columbia. And you know, it's grown well beyond British Columbia now. So saving lives around the world.  

Nicole  15:31 

That's really, really exciting. Thank you for sharing that. So, I mean, what would you say is the importance of this finding? Or what is it going to mean for the future of ovarian cancer?  

Gillian  15:45 

Yeah, I mean, I hope what it's going to mean is that, you know, we're going to see a lot fewer people with high grade serous ovarian cancer. You know, as I mentioned, there's been quite a bit of uptake around the world. So you know, I think in 2018, was the most recent data I saw, but there were nine different FIGO, which is the gynecologic, OBGYN the international OBGYN society, there were nine countries that had recommended opportunistic salpingectomy as of 2018. And so, you know, there, this has been done all over the world, we know that rates of uptake are quite high in many other countries. We have some Canadian data that suggests that, you know, outside of BC, there's room for improvement. So, you know, I hope it means that there'll be increased uptake of opportunistic salpingectomy, I hope that, you know, people, Canadians and people outside of Canada and around the world, hear about it and ask about it, if they're undergoing a hysterectomy or seeking permanent tubal sterilization. I hope, you know, if we started to do this for all people who were having one of those surgeries and wanted a salpingectomy, you know, we could really dramatically decrease numbers. So, you know, for example, in the Canadian paper, where we looked at uptake across Canada, there were 200,000 missed opportunities for a salpingectomy in the study period that we were looking at, which was between 2011 and 2016. And you know, if you assume about a 1% rate of ovarian cancer in that population, and, you know, say you assume that opportunistic salpingectomy is about 80% effective at prevention, it's hard for us to say, because we saw no high grade serous cancers in BC, so we can't say we, you know, assuming it's 100% effective is probably a little bit optimistic. But if you say 80%, for example, you know, that translates to about 1600, people who are going to get an ovarian cancer, who other who otherwise would not have if they had had this procedure at the time of their hysterectomy, or instead of their tubal ligation. And so, you know, to me, that's just what's really heartbreaking is that I don't want to see anyone who's had a missed opportunity, right, go on to get a high grade serous ovarian cancer, because, you know, as you both know, and as your listeners are probably aware, it's a really devastating diagnosis with, you know, a not a very favorable five year survival rate. So less than half of people will be alive five years later. So, you know, any opportunity that we have to prevent those cancers, you know, I, we hope that that people will take it and that this publication is going to be, um going to help sort of turn that tide from opportunistic salpingectomy being something that people were, you know, occasionally offering their patients or discussing with their patients to something that they'll really recommend and, you know, spend the time to really go through the evidence with their patients and make sure that they understand the possible benefits of, of having their tubes out at the same time.  

Stephanie  19:35 

Yeah, this is such a huge finding. And I think, like you said, Gillian, you know, it saves lives and it saves, you know, not just not just one person's life, but we talked about how many women or people who act as female figures in their families and their lives, plays such an important role in other people's lives. So I think it has a really important impact in that regard as well, as well as the potential cost savings to the healthcare system when we're preventing cancers from occurring. So what should our listeners do if they're listening to this episode, and they want to figure out if opportunistic salpingectomy, is appropriate for them? You know, what should they ask that provider? What What would you recommend? 

Gillian  20:27 

Yeah, I mean, at this point, we're still not recommending that, that people undergo a standalone surgery solely for the purpose of fallopian tube removal as an ovarian cancer prevention strategy because, you know, ovarian cancer, yes, it's a terrible disease, but it is also quite rare. And so, you know, we are not recommending that every person with fallopian tubes, who's done or not interested in having any future pregnancies goes to have them removed. Because, you know, that's not really necessary, the vast majority of people won't get ovarian cancer. And you know, that you're talking about cost effective, you know, sending hundreds of 1000s of people to the OR you now, is not not the end goal, right. So, what we are saying is that if you are a person who is undergoing some kind of a procedure, where there is an opportunity to remove your fallopian tubes, that you should discuss that with your surgeon. And so, while opportunistic salpingectomy to date has focused on hysterectomy and tubal sterilization as those two procedures, were we where we know we have an opportunity to remove fallopian tubes, there are other procedures where, where we think that opportunity salpingectomy can be done safely and effectively. And, you know, we're researching that right now we're starting a project looking at removing fallopian tubes at the time of colorectal surgery. There's been a group out of Austria that has looked at removing fallopian tubes at the time of cholecystectomy, which is gallbladder surgery, if you are having a a procedure in the abdomen, where you think that your surgeon might have access to your fallopian tubes, and you're interested in opportunistic salpingectomy as an ovarian cancer prevention strategy, you should talk to your surgeon about it. Because they you know, they may tell, you no this surgery, it's not appropriate, or we don't have the right tools, or we're not going to have easy access, but you'll never know unless you discuss it with them. So ask them. And then of course, if you are having a hysterectomy, or if you are seeking tubal sterilization for because you're not interested in having any future pregnancies, then, you know, discuss that with your provider because we absolutely know that it is safe. And we have good preliminary evidence of effectiveness at that time. Yeah, and I mean, I guess the other thing that people can possibly do is, you know, we make decisions about what contraceptive choices that we want to use, and, um, tubal ligation, tubal sterilization is sort of falling out of favor, for good reason, you know, they are, not because there's anything wrong with tubal sterilization, but because there are alternatives that seem easier. For example, vasectomy or an IUD. And so just, you know, maybe consider this as something to factor into that equation, when you're making decisions around what form of permanent and irreversible contraception you want to use, you know, obviously, an IUD is not permanent and irreversible. So you know, if you're not looking for permanent and irreversible go with the IUD, but it you know, many people use the IUD as a form of permanent and irreversible contraception now, and they just replace it every five years. And IUDs are great, and I would never tell you not to use one, but you're not, you know, you're not getting the ovarian cancer prevention benefits that you would get with salpingectomy. So that would be the other thing I guess that people that I would recommend to people is just to consider to consider this when you're considering what form of contraception you're going to choose.  

Nicole  24:54 

Yeah, never hurts to have the discussion or at least, you know, ask your health care provider and talk about it. We we talk a lot on this podcast about advocating for yourself. So, yes, that's one way you can do that. 

Gillian  25:07 

And if you have a family history, you know, that's the other piece of the puzzle is if you have reason to be concerned about your ovarian cancer risk, you know, if you have a family history, but you do not have a BRCA mutation, you know, often people have, you know, people have chosen to undergo salpingectomy as a way to decrease their risk for ovarian cancer if they're particularly concerned about the risk for ovarian cancer.  

Nicole  25:39 

Absolutely. So what is next for this research? Where does it go? What does the future hold?  

Gillian  25:48 

Yeah, I mean, I think, um, that the things that I'm most interested in right now are, how can we expand it to reach more patients to reach more people to prevent more cancers. So you know, beyond just hysterectomy, and tubal ligation are there other opportunities, the more people we can offer this to the fewer high grade serous ovarian cancers we're going to see in the future. So that's something I'm interested in. And then the other thing that I'm interested in as well is trying to understand when it might make sense to do a salpingectomy as a standalone surgery for people who do have an an increased risk of ovarian cancer. So you know, better developing risk prediction models, and then using that to target people who are at a higher risk for ovarian cancer and then offering those people opportunistic salpingectomy to prevent or, and, or dramatically decrease that risk for them. So that, you know, I think people don't necessarily aren't necessarily even always aware of what their ovarian cancer risk might look like, particularly if they don't have a family history. Um, but you know, there is likely a group of people that we could identify and, you know, offer them this opportunity, and they can, you know, decline it if they're not interested, but at least they were to have had the opportunity.  

Stephanie  27:30 

In terms of determining the, I guess, the publication that you shared with us today, is a fairly like preliminary evidence and early detection of whether or not it is effective in terms of kind of finalizing that bit of research or, you know, getting that, like, for sure, checkmark that it is effective against for preventing ovarian cancer, what would that entail? What would that require? 

Gillian  27:59 

Yeah, I mean, at this point, we just need longer follow up, and more patients. So, you know, we're working on that, obviously, um, and, yeah, like we, we have no reason to expect that this preliminary finding won't hold. But certainly, we will continue to investigate and to add to the patient population of people who've had opportunistic salpingectomy, and then also just wait, you know, wait longer to see if any, if any more cancers do arise in that group, or, you know, to get an accurate identification of how effective it is, and prevention as well, we'll need, we'll need more patients. And we'll need longer follow up time, which is already underway. Great, thank you so much. Well, that kind of wraps up today's episode. Thank you so much, Jillian, for coming on and sharing this really important and exciting finding and what that means for ovarian cancer prevention, as Nicole mentioned about kind of all of the we talk a lot about advocate advocacy, and patient advocacy on this podcast. And I'd also just encourage all of our listeners that if you're listening to this, and you're learning something new about opportunistic salpingectomy and ovarian cancer prevention, share it with a friend talk about it to your loved ones and just kind of spread the word and spread this message that this research is underway and we're discovering new things about ovarian cancer prevention as the years go by, so, thank you again, so much, Dr. Hanley for joining us and we look forward to hearing more about this work in the future.  Yeah, thank you so much for having me.  

Stephanie  29:54 

Thanks for joining us on the GOSH podcast. To learn more about the Gynecologic Cancer Initiative. In our podcast make sure to check out our website at gynecancerinitiative.ca