The Samuel A. Cosgrove Memorial Lecture this afternoon will consider the benefits and proper indications for salpingectomy.
During “Routine Salpingectomy — A Debate,” which starts at 4:15 pm in Hall D, Beth Y. Karlan, MD, FACOG, director of the Cedars-Sinai Women’s Cancer Program at the Samuel Oschin Comprehensive Cancer Institute, Los Angeles, will present evidence for making the procedure a new standard of care. Kevin J. Doody, MD, FACOG, fertility specialist and founder of the Center for Assisted Reproduction in Dallas and Forth Worth, Texas, will present the arguments against making salpingectomy more common for sterilization.
Dr. Karlan said that in addition to significantly reducing the risk of ovarian cancer, the procedure could improve overall health for women and reduce health care costs because it decreases the likelihood of additional post-hysterectomy surgeries.
New data shows serous adenocarcinoma, the most common type of ovarian cancer, often starts in the Fallopian tube and not the ovary, she said.
“There’s really a tidal wave of evidence from retrospective clinical pathological studies to animal models to molecular data that demonstrate that the cell of origin for the most common and most lethal epithelial ovarian cancers is the serous epithelium of the Fallopian tube,” she said.
Salpingectomy also makes sense to Dr. Karlan on a developmental and anatomic level because she considers the Fallopian tube as part of the uterus since it’s derived from the mullerian ducts. Only because of convenience have the tubes remained with the ovary since surgical clamps are placed at the uterine cornua.
“If you’re going to go back and be a purist, the tubes are actually part of the uterus,” Dr. Karlan said. “I’m actually teaching my residents and fellows to perform salpingectomies with nearly all hysterectomies.”
Dr. Doody said that while some evidence exists showing that many cases of ovarian cancer begins in the fallopian tubes, it would be premature to make wholesale changes in health care policy when it comes to long-term contraception.
“When we look at kind of the evidence or what we need from scientific studies to decide what the right clinical choice would be, we’d certainly like to have more than just opinions,” he said. “We’d really like to have, if not randomized control trials, at least some scientific trials, some more population-based cohort trials. They have not been done.”
The medical community has a history of taking some evidence and applying it to a broad population only to change its thinking once better trials have been completed. Dr. Doody points to the Women’s Health Initiative’s support of hormone replacement theory until a large trial was conducted and recommendation reversed.
Early mathematical modeling comparing salpingectomy vs. simple tubal ligation has shown that, on average, the salpingectomy extends a woman’s life by up to a week, Dr. Doody said. But that requires some big assumptions and assumes minimal negative consequences with the more radical procedure.
Many women who undergo sterilization change their minds despite undergoing counseling and understanding that the procedure is supposed to be permanent, Dr. Doody said. Sterilization reversal can take place following a conventional tubal interruption, but that option goes away for patients who have undergone sterilization by salpingectomy.
“I think people are scared of the word cancer, and if we bring out that word when we’re counseling our patients about contraception, it might steer patients toward something radical and irreversible like salpingectomy when really better, reversible options are maybe better for many patients,” he said.
During the debate, Dr. Karlan will discuss data from a population-based study of more than 250,000 Swedish women that found salpingectomy reduced ovarian cancer risks. Other studies have shown that removing the Fallopian tubes and leaving the ovaries is safe and does not cause premature menopause, pain and other surgical complications.
Dr. Karlan said that salpingectomy doesn’t prevent patients from future childbearing but just that they would need to use assisted reproductive technologies. She still upholds the recommendation to remove the ovaries once childbearing is complete in women at high risk or with BRCA mutations.
“If they’re doing it as a means to prevent cancer in high risk women, which is not really the main focus of the debate, then I think you need to weigh the risk-benefit and — as we continue to talk about personalized medicine — really individualize the risk assessment and recommendation for the woman sitting in front of you,” she said.