Salpingectomy - removal of fallopian tubes
Previously, all ovarian cancers were believed to develop in the lining of the ovary as a result of the constant rupture and repair process during ovulation. New research, however, suggests that many ovarian cancers in BRCA gene mutation carriers may actually start in the distal fallopian tube (part of the tube closest to the ovary), causing researchers to question whether salpingectomy (removal of the fallopian tubes) might reduce ovarian cancer risk.
Current expert guidelines recommend that women with BRCA mutations undergo bilateral salpingo-oophorectomy (removal of the ovaries and fallopian tubes) between the ages of 35 - 40 or after childbearing is completed. This surgery has been shown through research to improve survival in mutation carriers. However, the surgery also causes immediate surgical menopause, which can be accompanied by short and long-term side effects and health consequences.
Based on the emerging fallopian tube research, some gynecologic oncologists have proposed that interval salpingectomy—removing the fallopian tubes and leaving the ovaries intact until after natural menopause—might lower risk for ovarian cancer in high-risk women while avoiding the negative side effects and long-term health consequences associated with oophorectomy at a young age. After menopause women would then undergo a second procedure to remove their ovaries.
Before the medical community can accept salpingectomy as a risk-reducing option, much more research is needed to show that this option is safe and effective.
Several pieces of evidence suggest that the fallopian tubes may be the source of many hereditary ovarian cancers.
- Researchers established early on that fallopian tube cancer—which is rare in the general population—is more common in women with BRCA mutations.
- Careful examination of the fallopian tubes from research studies such as GOG-0199 led to the discovery of precancerous fallopian tube changes called “serous tubal intraepithelial carcinoma “ (STIC) lesions. These STIC lesions found in fallopian tubes appear to be “precursor” lesions that will develop over time into ovarian cancers. No similar lesions have been found in the ovaries of high-risk women
- STIC lesions have similar gene profiles as serous ovarian cancers.
- As many as 50% of women with BRCA mutations who have ovarian cancer also have lesions in their fallopian tube.
- Preliminary studies in cancer-prone mice show that removal of fallopian tubes prevents high-grade serous carcinoma of the ovaries—the type that women with BRCA mutations are most likely to get.
Even if the fallopian tubes are the cause of many gynecologic cancers in mutation carriers, researchers caution that there is not enough evidence to suggest that all of these ovarian cancer start in the fallopian tubes. More research is needed to completely understand the role of the fallopian tubes in the development of these cancers.
Before experts can recommend "interval salpingectomy"—removing the fallopian tubes and leaving the ovaries intact until after natural menopause—more research is needed on the safety, efficacy, and acceptability of this procedure for high-risk women.
FORCE conducted an online survey of 204 premenopausal women with BRCA mutations who had neither ovarian cancer or a risk-reducing removal of fallopian tubes and ovaries (salpingo-oophorectomy). Thirty-four percent of women surveyed said they would definitely be interested in a study of salpingectomy; approximately 83% of these women cited the possibility of reducing ovarian cancer risk without menopause as their motivation to participate. On the other hand, approximately 30% of women said they would not be interested in such a study, citing concerns about surgical complications, the possibility of ovarian damage, and potential cost. These findings suggest that there would be enough patient interest in the HBOC community to begin a clinical trial of risk-reducing salpingectomy. The survey results were presented as a poster at the annual conference for the Society of Gynecologic Oncologists.
Still, questions remain about the feasibility of conducting such a study. The Gynecologic Oncology Group, part of the National Cancer Institute’s Clinical Trials Cooperative Group Program approved further development of a study on salpingectomy, which would further examine the fallopian tubes of high-risk women who undergo the procedure and to assess:
- immediate and long term complications of the procedure
- impact of the procedure on ovarian function
- the proportion of women who ultimately undergo completion oophorectomy
- feasibility of conducting a larger trial to determine impact of the procedure on cancer risk.
In the meantime, FORCE and the University of Washington have organized a salpingectomy research registry to follow outcomes on women who have undergone this procedure.
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