ACOG Strengthens Support for Fallopian Tube Removal to Prevent Ovarian Cancer

Ob/gyns should routinely remove fallopian tubes during hysterectomy and recommend opportunistic bilateral salpingectomy (OBS) to patients undergoing other surgical procedures, according to a clinical practice update from the American College of Obstetricians & Gynecologists (ACOG).

Published in Obstetrics and Gynecology, this update strengthens ACOG’s support for OBS, which has a strong evidence base. Data from multiple studies have shown that removing the fallopian tubes is safe and can reduce a patient’s lifetime risk of ovarian cancer by as much as 78%.

“ACOG’s updated guidance represents the strongest recommendations to date supporting patients’ access to salpingectomy to reduce their lifetime risk of ovarian cancer,” said David Shalowitz, MD, of the Western Michigan University Homer Stryker M.D. School of Medicine in Kalamazoo, in an ACOG press release. “Obstetrician-gynecologists have an opportunity to empower patients through education, evidence-based practice, and collaboration with other medical and surgical specialists. For now, salpingectomy is the safest, most effective way to prevent this deadly disease.”

A recent study from Canada involving more than 80,000 patients showed that women who underwent bilateral salpingectomy at the time of hysterectomy had almost an 80% lower risk of developing serous ovarian cancer versus hysterectomy alone. Additionally, six of 26 (23.1%) cases turned out to be high-grade serous ovarian cancers as compared with 642 of 942 (68.1%) cancers in a historical control group.

“We’ve got good data to support [OBS], and it’s surprisingly kind of not well known,” said Karen Lu, MD, of the Moffitt Cancer Center in Tampa, Florida, commenting on the study when it was published. Although the Canadian study involved a somewhat younger population than the typical patient with ovarian cancer, “it is kind of continuous information that highlights that we have sufficient data to recommend opportunistic bilateral salpingectomy for women undergoing gynecologic procedures and even for women undergoing other abdominal or pelvic surgeries that are nongynecologic.”

Coinciding with the Canadian study, the European Society of Gynaecological Oncology published a consensus statement supporting OBS for ovarian cancer prevention. After reviewing 129 published articles, the consensus panel concluded that “existing evidence demonstrates that opportunistic salpingectomy is significantly associated with a lower risk of developing tubo-ovarian carcinoma. Clinicians should include this prevention intervention in preoperative counseling of eligible women.”

Consistent with Lu’s observation about the lack of recognition for the benefits of OBS, a study published last year showed that a fourth of 2,000 women with ovarian cancers had “missed opportunities” for risk-reducing OBS when they had surgery for permanent contraception or abdomino-pelvic procedures prior to cancer diagnosis. Moreover, 6% of the patients had a first-degree relative with ovarian cancer, 43.2% of whom were found to have genetic susceptibility to ovarian cancer that was discovered only after cancer diagnosis.

In addition to recommending routine OBS during hysterectomy, the updated ACOG guidance:

• Encourages clinicians to recommend OBS to patients who do not desire future fertility and are undergoing non-hysterectomy gynecologic surgery that enters the peritoneal cavity
• Recommends that ob/gyns consider successful completion of salpingectomy when counseling patients about potential surgical approaches, emphasizing the principles of informed consent and shared decision-making
• Stresses that bilateral salpingectomy is the preferred procedure for patients seeking permanent contraception
• Highlights the importance of cross-specialty collaboration in reducing the risk of ovarian cancer, noting that nongynecologic abdominal or pelvic surgery may afford opportunities for risk-reducing bilateral salpingectomy with minimal additional surgical risk

“Having cared for many women with ovarian cancer, I understand deeply the tremendous toll that complex surgery and multiple rounds of intensive chemotherapy can take on patients and their loved ones,” said ACOG CEO Sandra E. Brooks, MD, in ACOG’s press release. “Although advances in treatment have helped patients live longer, mortality from ovarian cancer remains high. Salpingectomy represents a meaningful opportunity to reduce a person’s risk of ever having to contend with this challenging disease.”