GOSH Podcast

Episode 5: What does Ovarian Cancer Prevention Look Like?

January 24, 2021
GOSH Podcast
Episode 5: What does Ovarian Cancer Prevention Look Like?
Show Notes Transcript

Dr. Gillian Hanley joins us on the GOSH podcast to discuss ovarian cancer prevention in British Columbia and around the world. She talks about the high uptake of opportunistic salpingectomy in British Columbia, a procedure that helps prevent ovarian cancer by removing both fallopian tubes at the time of other gynecologic surgeries. Dr. Hanley is an Assistant Professor at UBC's Department of Obstetrics & Gynecology and a health services/health economics researchers at OVCARE and the Gynecologic Cancer Initiative.

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Gillian

Really, internationally it's just been, sort of like you know, you watch a map and started in BC and then it's like boop, boop, boop, boop, boop, like all over the world, people making this recommendations.

Introduction

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 treatment outcomes. 

Our podcast is produced and recorded on the traditional, unceded territories of the xʷməθkʷəy̓əm (Musqueam), Sḵwx̱wú7mesh (Squamish), and səl̓ilwətaɁɬ / sel̓íl̓witulh (Tsleil-Waututh) nations. It is produced by the Gynecologic Cancer Initiative, a province wide initiative in British Columbia with the mission to accelerate transformative research and translational practice on the prevention, detection, treatment and survivorship of gynecologic cancers.

Nicole

Hi, I am Nicole Keay.

Stephanie

And I'm Stephanie Lam, 

Nicole

and you're listening to the GOSH podcast. Welcome to today's episode, we have with us Dr. Gillian Hanley, who is an assistant professor in the Department of Obstetrics and Gynecology at the University of British Columbia. She is a CIHR new investigator, Michael Smith Foundation scholar and Jen Cottrell foundation scholar. Her research focus combines her substantive interest in women's health with her training in economics, health services, research and epidemiology to answer questions related to gynecologic cancer, primarily ovarian cancer prevention, as well as healthy reproduction and pregnancy. Welcome to the podcast Gillian

Gillian

Thanks for having me. Excited to be here.

Nicole

Yeah, we're really excited to have you join us today. So to kick us off, can you tell us a little bit about your research program? 

Gillian 

Yeah, so um, I work primarily with the large population based administrative datasets in British Columbia. And I use these to really investigate questions around gynecologic cancer. And I'm particularly focused on the area of ovarian cancer prevention because ovarian cancer, while not being an incredibly common cancer is a very deadly cancer with an over 50% mortality rate within the first five years. And we have not made a huge degree of progress in changing that survival rate over the last 20 to 30 years. And unfortunately, despite considerable international effort, and a lot of you know, very large and well done randomized control trials, we have not been able to find an effective screening method for ovarian cancer either. So we are really trying to sort out the best approach to tackle this disease. And when we began to understand more about the difference between ovarian cancer histologic subtypes, which refers to the fact that within the last 15 years, we've come to understand that ovarian cancer is not a single disease, but actually five distinct diseases with different clinical characteristics and molecular characteristics and risk factors and even likely to soon be some differences in treatment options. We also came to realize that the tissue of origin probably differs for these cancer types as well. And so high grade serous ovarian cancer, which is the most common and the most lethal of the five types of ovarian cancer, it appears to originate most often in the fallopian tube and not on the ovary. And when that discovery was made, we realized that there was a real opportunity for prevention for this cancer type. And so I've been working in that area largely trying to understand how we can effectively prevent ovarian cancer.

Stephanie

So that's really interesting. I think it kind of highlights how important that finding of ovarian cancer being like distinct disease types, as opposed to being the single disease really changes how research is being conducted. I am curious though, Gillian, because I know that BC has had an ovarian cancer prevention strategy that started back in 2010. So could you tell us more about what that prevention strategies includes and how that has it been going now that we've hit the 10 year mark of the strategy being implemented? 

Gillian

Yeah. So the ovarian cancer prevention strategy largely focuses on opportunistic salpingectomy and that refers to removal of the fallopian tubes, when there is an opportunity to do so. And those opportunities were historically defined as, at the time of hysterectomy and instead of tubal ligation. So instead of having your tubes tied for permanent and irreversible contraception, the recommendation was to remove them completely. And both of those recommendations revolve around the idea, the theory that the fallopian tube is actually the tissue of origin for most high grade serous ovarian cancers. So if you have an opportunity to remove that tissue of origin, then you are potentially preventing a future high grade serous ovarian cancer. So that's the first two prongs of what was a three pronged ovarian cancer prevention approach. And the third recommendation that was made in 2010 was to refer all women who are diagnosed with a high grade serous ovarian cancer to the hereditary cancer program to be tested for a BRCA mutation. The reason for that recommendation was that we know that approximately 20% of high grade serous ovarian cancer patients have a BRCA mutation, either BRCA1 or BRCA2 deleterious mutation, but we also know that based on current guidelines for referral to the hereditary cancer program, only about 9% of those women would qualify, according to their family history and the criteria that we use right now for sending women for testing. And so the recommendation to send all patients with a high grade serous ovarian cancer was made in order to pick up a larger proportion of women with a BRCA mutation. And it's obviously too late to prevent a cancer in those women, they already have been diagnosed with a high grade serous cancer. So we've missed our prevention opportunity. But the idea is that we can then identify and test all of that woman's female relatives in order to capture other BRCA mutation carriers within her family. And if we know that somebody has a bracket mutation carrier at an early enough age, or even just prior to a development of a cancer, there are many effective prevention strategies that we can use to prevent not just an ovarian cancer, but also a breast cancer, which women with BRCA mutations are at increased risk for as well.

Stephanie

Mm hmm. I'm sorry, Jillian. So can you just further confirm? Because I think you confirm, you corrected me on this as well. So for opportunistic salpingectomy, you're only removing the fallopian tubes. Is that right? And why is that? 

Gillian 

Yeah, exactly, that’s right.  So really what we used to do, for example, with many women who are having a hysterectomy, if their ovaries were being left and not being removed, which we don't want to remove ovaries, particularly in younger women, because we know that production of endogenous hormones is really important for long term health outcomes, particularly things like cardiovascular disease, bone health, there's some indication that it can be important for cognitive function as women age. And so you know, we've made a concerted effort to stop removing ovaries as often as we used to, and now that we understand that there are these important health implications of ovary removal, which become more important, the younger the woman is at the time of her surgery. And so now, if we're removing a uterus and leaving the ovaries in situ, we used to leave the fallopian tube we used to not touch the fallopian tube because we didn't have any reason to remove that. But now we're saying if you're leaving the ovaries, don't leave the tubes remove the tubes and the uterus at the same time. But yes, it does not refer to removal of the ovaries because we are trying to leave as many ovaries intact as possible.

There are other reasons that women have their ovaries removed. And certainly, you know, one of the prevention approaches in women with BRCA mutations is in fact to remove the ovaries because their risk of ovarian cancer is just so high. And the evidence that we have to date is around removal of tubes and ovaries in that patient population. But when we're talking about opportunistic salpingectomy, we're talking about what we can do for women who are at general population level risk. So there, they don't have a genetic reason to be particularly concerned about ovarian cancer, we don't think they're at significantly higher risk for ovarian cancer. But of course, 80% of women who develop an ovarian cancer do not have a BRCA mutation. So you know, we still want to focus prevention efforts to women who are at general population level of risk as well. And this is one way of doing that. So we're not recommending that everybody have their tubes out if they have no other surgery planned, you know, we're not recommending that we send every woman for surgery. But we're saying if there's an opportunity, if you're already doing a gynecologic surgery, if you're already in the area of removing a uterus or ligating tubes, then remove the fallopian tube as well, because you are likely removing the tissue of origin for a future high grade serous ovarian cancer. And so hopefully, we can really make a dent in the impact of this disease by doing that. 

Stephanie

Kind of like a two in one deal. 

Gillian

Exactly. Yeah. If you're already in the area, right. That's why we call it opportunistic, because, you know, we're really saying if you've already got an opportunity, then take advantage of it. But we're not, we're not recommending that this be a de novo surgery, you know, for somebody who had no other reason to undergo a surgery.

Stephanie

Mm hmm. Before we jump into the research behind it, Gillian can you tell us more about you know, why a person might be, you know, doing surgery in that area? What is the patient demographic normally, who might be eligible for opportunistic salpingectomy? 

Gillian 

Yeah, so, I mean, there are lots of indications for why women end up having a hysterectomy. I mean, the sterilization one is obvious. So younger women who are seeking a permanent irreversible form of contraceptive contraception often choose tubal ligation. And so that's an obvious one there, they're just done with childbearing. And they, they're, you know, making a permanent sterilization choice. So we're saying rather than ligating, which is basically to cauterize, just remove the tube entirely. And for hysterectomy, women undergo hysterectomies for many, many reasons. So, you know, indications are things like fibroids, irregular bleeding, endometriosis can often be an indication, you know, benign growths or tumors can be an indication, prolapse can be an indication. So you know, a lot of benign gynecologic conditions often result in a hysterectomy, we are making a concerted effort to do fewer hysterectomies than we used to. It used to be a more common procedure than it is now. Because I think, you know, there are conditions that can be effectively treated through less invasive approaches. And we are seeing that, you know, there is a background of decreasing history of hysterectomy rates, but it still is one of the more common surgeries for women to undergo.

Nicole

So Gillian, so what does the research tell us about using opportunistic self inject to me as a prevention strategy then for ovarian cancer? 

Gillian

So because really BC led the way here, and we implemented this recommendation for opportunistic self inject me before anybody else in the world really. So and because you know, it's only 10 years old, and ovarian cancer is a relatively rare cancer. We don't have the effectiveness data yet. So what we've really been up to the last 10 years is understanding this safety really. Because we don't want to recommend a procedure and then find out that there's some kind of unintended negative. So we've been doing a lot of work around understanding. First of all, we wanted to know, did people actually change practice? So, you know, were they now performing salpingectomy at the time of hysterectomy and in lieu of tubal ligation after the recommendation was made. And then we wanted to understand was there any indication of adverse events and we started with sort of the big perioperative events. So things like were they more likely to be re-admitted to hospital, were they more likely to require a blood transfusion, were they more likely to have a longer length of stay in hospital following their surgery, those types of things that would suggest some pretty important and serious adverse events. So that's where we started. And we reported no differences in any of those outcomes. And I should note that also there was a lot of work done before I joined the research team at OVCARE to survey physicians and obstetrician gynecologists around the province to understand what they were concerned about. And so, you know, we took their concerns into consideration when we designed a lot of the outcomes that we looked for. And so we did that work in both Canadian data, British Columbia data and then also American data, and found that the safety looked good in both countries. And then we looked at more minor, possible minor complications as well. So things like were women who had an opportunistic salpingectomy more likely to be in their doctor's office more often within you know, two weeks following their surgery? Were they more likely to have an infection? Were they more likely to use an antibiotic? Were they more likely to fill a prescription for a prescription level analgesic? Were they more likely to be sent for imaging and so a CT or an ultrasound following their surgery? 

So we really, really wanted to just shake the trees and say, is there anything that we can see here that would lead us to feel concerned about opportunistic salpingectomy, compared to hysterectomy alone, or tubal ligation. So all of this work always compares to the surgery that women would have received had the recommendation not been made. So hysterectomy alone, or tubal ligation is always our comparator group. And the only thing that we found was that women who had an opportunistic salpingectomy were slightly more likely to fill a prescription for a prescription level analgesic in the two weeks following their surgery. But that that had that difference had been completely eliminated by one month following surgery. So there was no indication that they were returning to fill another script, they would just fill one. So we think that this is probably related to physician practice variations. So doctors who do opportunistic salpingectomy might also be more likely to write adjusting case script wrote for a prescription analgesic. But there's no evidence to suggest that there's any long term use of prescription level analgesics in women who undergo opportunistic salpingectomy, but of course, we can't rule out that that it's not, it could potentially be slightly more painful than the comparator surgery, we can't rule that out. So we would have to actually survey women following the two different surgical approaches to see if there is any difference there. But otherwise, we've seen no difference in any of our outcomes. And then the most recent study that we did, which I think is the most important as well, is that there was concern around the fact that opportunistic salpingectomy may decrease the age of onset of menopause. And the reason… the thinking there was that if it somehow disrupts blood flow to the ovary, it could possibly lower the age of onset of menopause. And that is a really important outcome because we know that decreasing the age of onset of menopause is associated with all of those other complications that I mentioned when I was discussing why we don't remove ovaries as often as we used to. So lowering the age of onset of menopause also increases cardiovascular related mortality and those types of events as well. And so that's one that we're that we're really, really taking seriously. And our most recent publication on that which was, came out this year in American Journal of Obstetrics and Gynecology showed that there's no difference in time to initiation on hormone replacement therapy, and that there's no difference in time to first physician visit for concerns around menopause in women who've undergone opportunistic salpingectomy compared to women who've undergone the comparator surgeries. So all evidence today indicates that there it does not appear to be a decrease in age onset of menopause resulting from opportunistic salpingectomy. But of course, the million dollar question is whether or not we are effectively preventing ovarian cancers. And we do still need a little bit more time to answer that question properly, because we need to power it according to, what matters there is how many people have had opportunistic salpingectomy, but also how much time has passed since the opportunistic self inject to me in order for them to have had enough opportunity to have developed a cancer. So we expect that we'll be able to answer that question within the next couple of years. But we don't we aren't able to do that yet.

Nicole

So you mentioned that here in BC was one of the first places that was doing this work before anyone else in the world. What have you seen then take place on a more global scale? Like has this research been repeated? Or are you seeing it growing?

Gillian

I know certainly, there are definitely other people who are looking into opportunities salpingectomy a lot. We're not the only researchers I mean that particularly around the menopause question for example, there have been some set a lot of researchers around the world who've done short term studies of hormone levels following hysterectomy alone and hysterectomy with opportunistic salpingectomy and they've reported no difference. So looking at things like a AMH, FSH and estrogen like those kind of hormone levels following surgery. And then so there are other people who are doing the research. So other people are doing safety research on opportunistic salpingectomy as well. And that is also been largely reassuring. But I think that most important international effect of all of this is that many different medical societies have followed suite and made similar recommendations. So we made ours in 2010. And then GOC the gynecologic oncology society of Canada followed suite in 2011. And then SoGC, which is the Society of Obstetrics and Gynecology of Canada made a larger, broader recommendation in 2015, I believe. And then in the end, then the Americans made a recommendation that was nearly identical to the BC one in 2015, as well, I think and then the Royal College of Obstetrics and Gynecology in the UK, Australia, different European countries, there's some countries in Asia who now have similar recommendations. So really internationally, it's just been sort of like, you know, you watch a map and started in BC and then it’s boop, boop, boop, boop, boop, like all over the world, making this recommendation. So you know, we feel a high degree of responsibility to do this research and to do it properly. Because, you know, we really were, we're out front on this one.

Nicole

Mm hmm. So, question that I have for you, if we you know, the hope with this podcast is we are going to reach both clinicians, but patients and perhaps loved ones, if there is someone who has maybe just been diagnosed with an ovarian cancer, is this are there questions that they might want to ask around? opportunistic salpingectomy or things to consider if this was presented as an option of, I guess, not treatment, but as a surgery option for them?

Gillian

Well, so for people who have been diagnosed with a cancer, you know, the prevention opportunity has already been missed so for that group, it would really be more about talking to their female relatives. One thing, for example that I do regularly is like the women in my life, if there's a conversation and somebody saying, “Oh, I think I'm gonna have my tubes tied after this C-section that I'm having in a few weeks”…I'll just always say “no, don't have them tied, have them removed,” you know, and then we'll talk about, about why it makes more sense to have them removed. So I think just generally, that's more the conversation that I try to have with people and, you know, the public as well is, is around just being aware that if you're going in for a hysterectomy, or you're, you're thinking about permanent and irreversible contraception method that, you know, opportunistic salpingectomy is, is something that you should consider because you are potentially going to prevent a future ovarian cancer, and, you know, save a life by having those tubes removed. So that's really, it's less unfortunately, it's less an option for people who already have a cancer because they'll have, you know, tubes and ovaries and, you know, all of that removed as part of their as part of their treatment, but certainly for family members who are concerned. Now, again, if they have a high grade serous cancer, they should, they should go to see hereditary cancer, and to determine whether or not they're a mutation carrier, right, they are a mutation carrier than the prevention approach for relatives would be more aggressive, and should be, you know, they should just be more aware. And then that's two fold risk for ovarian and breast cancer. So, um, so if somebody is diagnosed with a high grade serous ovarian cancer, I think the main thing would be get tested for BRCA mutation. You know, let your female relatives know if you test positive, encourage them to go in and get tested. And then just in general, if you are hearing or speaking with people who are looking for a permanent irreversible contraception method, or considering tubal ligation or having a hysterectomy for any benign indication to just discuss, recommend that they discuss with their provider, opportunistic salpingectomy as something that's done at the same time or in lieu of for tubal ligation

Nicole

Right. So we know ovarian cancer is one of…or is the deadliest gynecologic cancer, and there's so much going on in this area research wise. Is there anything else that you're working on in the in this area that you want to share with us?

Gillian

Yeah, I mean, we're, we're also starting a program of research in survivorship in ovarian cancer as well. So, you know, we're interested, not just in preventing cancers and saving lives, of course, that's a priority, but also in improving the lives of people who are living with and beyond ovarian cancer. So that's another area where we've been doing some active research. And so you know, there's a program of research now around falls prevention in people with ovarian cancer, because there's been some indication that the risk for a fall related injury is particularly high in people with ovarian cancer. And so our data have suggested that about one in six people with ovarian cancer have a fall related injury, which is a really, really high rate, and that's obviously has important implications for quality of life for people living with and beyond ovarian cancer. So we're actively pursuing research to determine what underlies that risk. So can we understand a little bit more about why there are so many falls happening? And then if once we have a better sense of what is the underlying cause of that, then we can design more effective interventions. But in the meantime, because there is such a dire need for an intervention to try and reduce some of this risk. I'm working with some colleagues including Dr. Kristin Campbell, who's a physical therapist on a pilot of physical activity intervention for people with ovarian cancer. And it's designed both just to improve general quality of life because the evidence around physical activity and quality of life is pretty good in cancer patients, but also to see if we can reduce risk for falls as well.

Stephanie

Gillian, I did have another question. Going back to the prevention strategy. So you mentioned how, you know, this has been a, like a practice changing initiative that BC started. You know, could you tell us more about the struggles or the barriers and challenges to implementing such a strategy across the province? I'm sure you were working with a lot of community based gynecologists and others. So I'm curious to know what, you know, what were some of the challenges to that? 

Gillian

Well, so I was not personally involved in 2010. I was actually still doing my PhD at that time.  So you know, the educational campaign was primarily driven by Diane Miller, Sarah Finlayson, Jessica McAlpine, and others, and they did. Like they filmed a DVD and they sent the DVD around. And they talked about this at research days with OBGYNs across the province, and actually, we did a study on…so it was really remarkably effective in BC and almost instantly, I mean, you can track the change in progress almost to the month of the education campaign. And, and really, the uptake was, you know, remarkable. Like you just don't often don't see practice change like that. So we went from, you know, doing nearly no salpingectomies for sterilization, to doing 50% of them for sterilization. And then now we do about 80% of our hysterectomy where ovaries are left in situ include a salpingectomy. That’s huge. It’s remarkable practice change. And so we did do a study to try to understand why it was so effective. And we actually compared with Ontario, where uptake was not as swift and dramatic. And the some of the important factors that came out in that research was having a change leader. So you know, the, the role of Dianne Miller as somebody who is really seen as a leader in obstetrics and gynecology in British Columbia, and she was a champion for this initiative made a really big difference, because the community trusted her already. And so when she recommended this change, you know, they trusted that she was recommending something that made sense, and, and you know, what's going to help women in this province. Also, providers reported feeling really disheartened with ovarian cancer in general, and just, you know, what, stating what a devastating diagnosis it was. And so if there was anything they could do to prevent that from happening, you know, they were keen to try to, and then that, that there was sort of a saturation of this message kind of all at the same time. So they were hearing about it from their colleagues, they were reading about it in journal articles, and they were hearing about it in the news, because there was a big Vancouver Sun story that that was done around the campaign as well. And so it was kind of coming at them from a bunch of different sources. And that didn't…none of those things happened in Ontario. So those seem to be really important factors and why the educational campaign was so successful in BC. Now, having recently seen some preliminary numbers for Canada, it looks like uptake has really grown considerably in other provinces in Canada as well. More recently, so I think, you know, we're gonna have some updated Canadian numbers really soon. Hopefully, by the end of the calendar year, we'll put out that publication and, and I think the news is going to be really good in terms of what the other provinces are doing as well. And likely what we'll probably have made a big difference for the rest of Canada will have been the SOGC recommendations that came out in 2015, I expect. Yeah, we'll see. We'll see where everybody else ended up very soon. But I think, I think it's, you know, the practice change has happened really, beyond BC now as well, you know, whereas uptake was super dramatic really early here, I think we'll see that uptake is really grown across the rest of the country now as well. 

Stephanie 

I think those are important points to consider when doing, I guess, implementation of our research practices and stuff. Nicole, do you have any other questions?

Nicole

I'm just out of like, sheer curiosity, you mentioned that there was no screening tool for ovarian cancer. How far off do you think we are from that? Like, is that a long time coming? Or are we making any strides in that area?

Gillian

Yeah, I mean, we had some conversation with this. So this is not my particular, you know, area of expertise. But we had some conversation about this with Dr. Blake Gilks in the trainee webinar series, actually, he was answering some questions about this. And, and the idea is that it's actually probably not that we, we don't have a technology that could be useful. It's that it's the way the cancer develops that is problematic. So it seems to be, you know, really aggressive and fast moving. So you know, there are, there are many, many sort of anecdotes of patients who had a surgery at gynecologic surgery. And surgeons were, you know, looking at two perfectly healthy ovaries. And then six months later, there was a high grade serous cancer and a massive tumor, right. And so unfortunately, like, Dr. Gilk’s perspective was that it may just not we may just not be able to effectively screen for it, because it is not screenable. There's a certain requirements, you know, from a technology side, and then from a tumor side to make an effective screening program. And one of those is that there's a relatively long period where you're in sort of that pre diagnostic phase, but there is, you know, like dysplasia of some sorts, that can be detected. And it does not appear that that's how high grade serous ovarian cancers work. Unfortunately, if we could see, you know, get super close images of fallopian tubes somehow and determine, you know, if there were sticks in them, but that's just not possible, because you have to actually, you know, see the tissue under a microscope to do that, though, I'm not sure. There was a big trial in the UK called the CTOCS trial, and they came the closest, and they used a combination of ultrasound, and blood and, you know, there's an algorithm that's patented, so it's not nobody knows exactly what it's doing, except for the patent holders. But they suggested that, that there may be a slight advantage in the screening group, but they didn't detect it within their original study time. And they think that as they follow sort of five more years out, they may detect a slight advantage in the screening group. But it doesn't really look great for cost effectiveness, because it's a pretty, you know, to screen all women for ovarian cancer and then to have just a really moderate improvement in mortality is not going to likely not gonna be a cost effective approach. But again, we'll just have to wait for the rest of those results to come out from that trial to really to be able to say one way or another.

Stephanie

That's really interesting. I think. Nicole, I'm thinking about cervical cancer and how they, for cervical cancer they there is that window of opportunity for screening, which is why I think so many folks are, you know, encouraging HPV screening as well as HPV vaccines and stuff because cervical cancer does offer that opportunity, but it's interesting to hear that not all cancers offer that in order to effectively do it on a population level. 

Gillian 

Yea, access to the tissue is helpful too, right? The fact that you can swab a cervix without having to open up…right? You can access that tissue. 

Nicole

Yeah, absolutely. I mean, yeah, I was just going to say that you mentioned that there’s five different types of ovarian cancers and I can imagine that that makes it even more challenging when you’re looking at either, you know, screening, or prevention, or treatment even in just trying to manage all 5 different types and you know, if they act differently, that just makes things  a whole lot more complicated

Gillian 

Having said that, the vast majority of ovarian cancer is for high grade serous cancers so they're responsible for about 75% of all cancers and about 90% of all deaths, so they seem to be the most aggressive. But I think that's a really important point to make...not to say that we only care about high grade serous ovarian cancer but that we've largely focussed all our efforts there. So you know I think one of the things that's so great about what we're doing in BC is that we have researchers who are focussed on the other less common ovarian cancer types as well and are really making some important headway there too because we need to consider all of them…all five...and not just always focus on high grade serous. 

 

Although you know, opportunistic salpingectomy, again because high grade serous is the kind that seems to arise primarily in the Fallopian tubes. Not exclusively, there is some suggestion that some do arise on the ovarian surface epithelium but the vast majority seem to arise in the Fallopian tubes so that's really what we're trying to tackle here with opportunistic salpingectomy. And then people like making Mike Anglesio and David Huntsman and others are doing some really important work. Mark Carey does really good research for low grade serous ovarian cancers so there’s lots of other important and interesting things going on for the other ovarian cancer types too

Stephanie

Hmm, that's great to hear. Okay, well I think that wraps up our episode. So Gillian we're going to have to invite you back on to the podcast once we get those updated numbers on how opportunistic salpingectomy is doing and we're really excited to hear about the research going on in the survivorship space so as you're making strides in those areas were going to have to...you're going to have to keep us updated on those as well. 

Gillian

Yes I'd love to you! 

Stephanie

So thanks so much Gillian for coming on! 

Gillian 

Thanks very much for having me 

Outro

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