Over the past 2 decades, we have learned that a majority of what is thought to be high-grade serous ovarian cancer in fact originates in the fimbriated end of the fallopian tube. Data from multiple studies have shown that the outer cells of the distal fallopian tube are transformed into malignant cells and subsequently spread to the neighboring ovary.

 This implies that surgical removal of the fallopian tubes may prevent certain types of ovarian cancer.

Our new understanding of the pathogenesis has given rise to a promising prevention strategy for women at an average risk of developing ovarian cancer through surgical removal of the fallopian tubes, referred to as an opportunistic salpingectomy (OS).

OS refers to the removal of fallopian tubes instead of tubal ligation, or during hysterectomy, while leaving the ovaries intact. Study findings suggest that OS is associated with an ovarian cancer risk reduction approaching 80%.

 Recent findings from 1 of the largest cohort studies conducted to date show that none of the 25,000 women in the study’s OS cohort developed a serous ovarian cancer throughout the duration of the study.

 Additional data have demonstrated that OS is safe and cost-effective and has not shown indications of an earlier age of onset of menopause.

With the hope of expanding the surgery to even more women across the population who have completed childbearing, investigators have moved to assess the efficacy of OS during nongynecologic surgeries, such as during removal of the appendix or gallbladder, colorectal surgery, hernia repair, and others. This opens a window of opportunity for hundreds of thousands of women undergoing these procedures annually.

A prospective European feasibility study of 105 women investigating OS during elective cholecystectomy found that surgeons performed the procedure successfully in 93% of cases. The median additional operating time was 13 minutes (range, 4-45).

 A cost- analysis study looking at qualityadjusted life years has suggested that OS during nongynecologic surgeries can be a cost-effective strategy to prevent ovarian cancer among average-risk women.

The Markov Monte Carlo simulation model by Kwon et al demonstrated OS with hysterectomy was less costly ($11,044.32 ± $1.56) than hysterectomy alone ($11,206.52 ± $29.81). Additionally, for surgical sterilization, OS was more cost-effective long term with an incremental ratio of $27,278 per year of life gained.

Despite the projected cancer prevention and population health benefits of OS during nongynecologic surgeries, these results have been seldom reported and surgeons rarely conduct the procedure outside early studies as there are currently no guidelines to rely upon. It is imperative that we delve further into this novel prevention strategy with prospective trials. This will require buy-in, collaboration, and training from both general and gynecologic surgical teams. Cross-disciplinary efforts to garner more information regarding long-term effects and outcomes will be necessary before OS conducted during nongynecologic surgeries can become a standard recommendation for women who have completed childbearing.

If achieved, widespread implementation of OS holds the potential to reduce ovarian cancer mortality in the United States by 15%—the equivalent of thousands of lives saved.

 Surgery has always been an all-encompassing team sport, requiring the collaboration of all teams involved to work toward improved outcomes for individual patients. OS now has the potential for surgical teams to join forces in the hopes of improving outcomes for women across the world.

The future widespread implementation of the OS serves as an opportunity for fellows across different surgical specialties—including but not limited to gynecologic, colorectal, general, urologic, and hepatobiliary—to collaborate. First, raising awareness regarding the potential of OS across different specialties is essential. Next steps will include expanding training during residency and fellowship across various disciplines, which will help with feasibility as well as future implementation. This will require both buy-in and teamwork from many to learn the OS procedure in a safe and effective manner.

Ryan M. Kahn, MD, is a gynecologic oncology fellow at Memorial Sloan Kettering Cancer Center in New York, NY. 

Sushmita Gordhandas, MD, is a fellow in the Gynecologic Oncology Department of Surgery at Memorial Sloan Kettering Cancer Center in New York, NY. 

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Articles

A new understanding of pathogenesis has given rise to a promising prevention strategy for women at an average risk of developing ovarian cancer through surgical removal of the fallopian tubes, referred to as an opportunistic salpingectomy. 

Ovarian Cancer Prevention With the Opportunistic Salpingectomy: An Opportunity for Multidisciplinary Collaboration

Widespread germline testing in the United States could prevent cancer in hundreds of thousands of people. However, despite known benefits, uptake for genetic testing has been slow: only 1 in 5 individuals use recommended genetic services even when there is a significant family history of colorectal, breast, or ovarian cancer.

The most commonly cited barriers to testing are lack of awareness, difficulty of access, and cost.

 Early detection of hereditary cancers and subsequent medical or surgical intervention decreases mortality, therefore this missed opportunity means an immense loss of lives.

Cascade testing identifies individuals who unknowingly carry pathogenic variants in cancer-susceptibility genes through familial diffusion of genetic risk information. Once a patient receives a diagnosis, genetic testing can be extended to at-risk relatives so that those who carry the familial pathogenic variant can take advantage of cancer surveillance and disease-reducing surgery.

Approximately 10 million women in the US without a personal history of cancer are at risk of carrying a cancer-susceptibility mutation have not undergone genetic testing. A 2020 study projected that widespread peri-diagnostic cascade testing in the US with an uptake rate of 70% had the potential to achieve population-wide identification of all susceptibility mutations within 10 years.

As long ago as 2014, the CDC designated cascade testing a tier 1 genetic application for hereditary breast, ovarian, and nonpolyposis colorectal cancer (Lynch syndrome).

 But its promise will be realized only when the barriers to testing have been eliminated. Because one of the biggest is lack of awareness, we developed a website to address it, with support from our principal investigator–Melissa Frey, MD, assistant professor of gynecologic oncology at Weill Cornell Medicine–and funding from the Foundation for Women’s Cancer and the Perlman Family CCARE Lynch Syndrome Research Foundation.

Providing Resources for Patients and Physicians 

A free portal, CascadeResources.net lists entities that provide cancer screening guidelines, genetic testing, variant interpretation, counseling, financial assistance, and support forums. The Network is a nonprofit, independently run organization unaffiliated with any of the entities listed or linked to on the site. 

As gynecologic oncology fellows, we focus on surgery, medical oncology, and clinical medicine. So when it came to developing the portal, we turned to the website building and hosting company Squarespace, which made the process much easier for us novices. 

Since our launch in October 2021, monthly page visits have steadily increased, and the network continues to expand. As more organizations discover us and ask to be included, we will be able to provide additional resources. 

New members have also joined the team: Hannah Bergeron and Muhammad Danyal Ahsan, research assistants at Weill Cornell Medicine, and Emily H. Miller, MD, MPH, an OB-GYN resident at NewYork- Presbyterian Weill Cornell.

We are building a page to help patients and providers navigate ClinicalTrials.gov when searching for trials of specific pathogenic variants, and developing instructional videos for physicians on how to discuss cascade genetic testing with patients and their relatives. To increase the Network’s visibility and scope, we are collaborating with news and research outlets and investigating search engine optimization. 

CascadeResources.net has been a fulfilling project and one that we hope will continue to be of use for patients, their families, and health care providers.

Offit K, Tkachuk KA, Stadler ZK, et al. Cascading after peridiagnostic cancer genetic testing: an alternative to population-based screening. 

2020;38(13):1398-1408.doi:10.1200/JCO.19.02010

Finch APM, Lubinski J, Møller P, et al: Impact of oophorectomy on cancer incidence and mortality in women with a BRCA1 or BRCA2 mutation. 

2014;32(15):1547-1553 doi:10.1200/JCO.2013.53.2820

Frey MK, Kahn RM, Chapman-Davis E, et al. Prospective feasibility trial of a novel strategy of facilitated cascade genetic testing using telephone counseling. 

 2020;38(13):1389-1397. doi:10.1200/JCO.19.02005

Centers for Disease Control and Prevention. Tier 1 genomics applications and their importance to public health. March 6, 2014. Accessed January 21, 2022. bit.ly/3Ioet2n

Sushmita Gordhandas, MD

Articles

Ovarian Cancer Prevention With the Opportunistic Salpingectomy: An Opportunity for Multidisciplinary Collaboration

Two Fellows Use Online Resources to Boost Genetic Testing