Removing the Fallopian Tubes May Reduce Ovarian Cancer Risk

The procedure is called opportunistic salpingectomy (OS), and it involves removing the fallopian tubes during a hysterectomy procedure, which is the removal of the uterus.

"For several decades, there has been a hypothesis which has suggested that actually, ovarian serous cancer originates from the fallopian tube," said M. Bijoy Thomas, M.D., a gynecologic oncologist with the Lehigh Valley Health Network in Pennsylvania. 

"So if fallopian tubes are removed preventatively, a woman is unlikely to get serous ovarian cancer," Thomas continued. "The recent JAMA publication looked at a large population of women who had a hysterectomy performed and found no serous carcinoma in women who had the fallopian tubes removed at the time of the hysterectomy."

Researchers looked at data from more than 25,000 women in British Columbia who had an OS performed at the time of a hysterectomy procedure. The Canadian province of British Columbia was one of the first places to formally recommend OS preventively, so the researchers had more than a decade of data to use.

"We started our study in 2008 because there were some very early adopters in B.C. who had already started practicing OS before the official recommendation, as they were reading the science that was being published about the fallopian tube being the tissue of origin for many high-grade serous ovarian cancers," said the study's senior author, Gillian Hanley, Ph.D., an associate professor of obstetrics and gynecology at the Vancouver Coastal Research Institute. 

"Because follow-up time—watching what happens to people who have their fallopian tubes removed for as long as we possibly can—is so important to understanding how effective this will be in preventing ovarian cancer, we wanted to use all the data we had," Hanley explained. 

The results were quite stunning: Of the women who had an OS at the time of their hysterectomy, absolutely zero developed ovarian cancer. This result was far below the age-adjusted rate of 5.27 serous cancers that would be expected in a group that size.

"The amount of ovarian cancer that can be prevented through the use of opportunistic salpingectomy depends on several factors," Hanley said. "The first is how effective OS is in preventing ovarian cancer. While our study suggests [preventive OS] will be quite effective, the numbers are small, and more follow-up is needed to understand exactly how much risk is reduced through OS. 

"The second [factor] is how many people have their fallopian tubes removed," Hanley continued. "As of right now, this is recommended during hysterectomy and instead of tubal ligation for sterilization, but we and others are currently working on expanding the surgeries in which OS is being offered." 

The results also uncovered a specific, technical aspect of OS procedures that could go even further in preventing ovarian cancer. The study appears to provide further evidence that one end of the fallopian tube—the fimbriated end, with its finger-like projections through which the egg moves from the ovary to the uterus—is where serous cancer originates.

"Our study provides the first prospective evidence showing that people undergoing OS for the purpose of ovarian cancer prevention were less likely to get ovarian cancer," Hanley said. "This is an important difference from some of the historical studies that have shown a reduced risk in people who had fallopian tubes removed for medical indications, [such as] ectopic pregnancy, as there was no reason historically for surgeons to carefully remove the entire fimbriated end of the fallopian tubes. 

"Now that we are doing OS for primary prevention of ovarian cancer, we hypothesize that surgeons are being much more careful to remove that entire fimbriated end and, thus, are removing more of the tissue of origin for ovarian cancer than was done historically," Hanley said.

Researchers looked at data from more than 25,000 women in British Columbia who had an OS performed at the time of a hysterectomy procedure. The Canadian province of British Columbia was one of the first places to formally recommend OS preventively, so the researchers had more than a decade of data to use.

"We started our study in 2008 because there were some very early adopters in B.C. who had already started practicing OS before the official recommendation, as they were reading the science that was being published about the fallopian tube being the tissue of origin for many high-grade serous ovarian cancers," said the study's senior author, Gillian Hanley, Ph.D., an associate professor of obstetrics and gynecology at the Vancouver Coastal Research Institute. 

"Because follow-up time—watching what happens to people who have their fallopian tubes removed for as long as we possibly can—is so important to understanding how effective this will be in preventing ovarian cancer, we wanted to use all the data we had," Hanley explained. 

The results were quite stunning: Of the women who had an OS at the time of their hysterectomy, absolutely zero developed ovarian cancer. This result was far below the age-adjusted rate of 5.27 serous cancers that would be expected in a group that size.

"The amount of ovarian cancer that can be prevented through the use of opportunistic salpingectomy depends on several factors," Hanley said. "The first is how effective OS is in preventing ovarian cancer. While our study suggests [preventive OS] will be quite effective, the numbers are small, and more follow-up is needed to understand exactly how much risk is reduced through OS. 

"The second [factor] is how many people have their fallopian tubes removed," Hanley continued. "As of right now, this is recommended during hysterectomy and instead of tubal ligation for sterilization, but we and others are currently working on expanding the surgeries in which OS is being offered." 

The results also uncovered a specific, technical aspect of OS procedures that could go even further in preventing ovarian cancer. The study appears to provide further evidence that one end of the fallopian tube—the fimbriated end, with its finger-like projections through which the egg moves from the ovary to the uterus—is where serous cancer originates.

"Our study provides the first prospective evidence showing that people undergoing OS for the purpose of ovarian cancer prevention were less likely to get ovarian cancer," Hanley said. "This is an important difference from some of the historical studies that have shown a reduced risk in people who had fallopian tubes removed for medical indications, [such as] ectopic pregnancy, as there was no reason historically for surgeons to carefully remove the entire fimbriated end of the fallopian tubes. 

"Now that we are doing OS for primary prevention of ovarian cancer, we hypothesize that surgeons are being much more careful to remove that entire fimbriated end and, thus, are removing more of the tissue of origin for ovarian cancer than was done historically," Hanley said.

As far as how this study's results may impact real-world decisions, there appears to be very little downside to adding opportunistic salpingectomy to a hysterectomy. 

"Robotic-assisted laparoscopic hysterectomy with removal of fallopian tubes, also known as bilateral salpingectomy, in experienced hands takes 45 minutes to one hour," Thomas said. 

"Robotic technology is so precise, the amount of trauma associated with surgery is minimal," Thomas continued. "Patients usually take Tylenol and ibuprofen and do not rely on narcotics for pain management. Most patients go home the same day."

According to Thomas, who recently performed his 2,900th robotic-assisted surgery and does the procedure 15 to 20 times per week, any additional risk and difficulty of adding OS to a hysterectomy procedure is negligible.

"All patients who undergo hysterectomy, especially minimally invasive, robotic-assisted laparoscopic hysterectomy, are good candidates for the procedure," he said. "Removing the fallopian tubes at the time of the hysterectomy would add one to two extra minutes with minimal blood loss and no anticipated complication."

Researchers like Hanley and surgeons like Thomas are hopeful that the study's results can be used to help prevent serous ovarian cancer in more people moving forward.

Considering what a horrific and deadly condition it is, any progress toward reducing ovarian cancer is welcome.

"This is a really exciting finding in a disease that has not had a lot of reason for excitement," Hanley said, adding that high-grade serous ovarian cancer is the most common (around 70 percent of all ovarian cancers) and the most lethal (about 90 percent of deaths from ovarian cancer) form of ovarian cancer.

"The recent bad news around screening showing that a combination of ultrasound and CA125 screening—I'm simplifying this here—was not effective in reducing deaths from ovarian cancer really solidifies how important prevention is for ovarian cancer," Hanley continued. 

"Also, while detecting cancer early is great, preventing someone from ever getting cancer in the first place is substantially better," Hanley said. "Thus, we are hopeful that through careful expansion to other pelvic surgeries and increased international uptake of OS, we can reduce the burden of this disease and save many lives around the world."