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Professor and Chair, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Connecticut Health Center, Farmington
Dr. Brewer reports no financial relationships relevant to this field of study.
SYNOPSIS: The role of routine salpingectomy during vaginal hysterectomy is controversial.
SOURCE: Cadish LA, Shepherd JP, Barber EL, Ridgeway B. Risks and benefits of opportunistic salpingectomy during vaginal hysterectomy: A decision analysis. Am J Obstet Gynecol 2017;217:603.e1-603.e6.
The question of whether routine salpingectomy should be done at the time of hysterectomy or adnexal surgery to prevent ovarian cancer is controversial. There are not convincing data whether the fallopian tube is always, sometimes, or occasionally the site of the high-grade serous carcinomas of the ovary. Multiple studies have determined that women with a deleterious BRCA mutation who undergo prophylactic bilateral salpingo-oophorectomy (BSO) and who have microscopic carcinoma actually have cancers that arise from the fallopian tubes 75% of the time and only 25% of the time from the ovary.1-3 Studies in patients with ovarian cancer who are not known to carry a deleterious BRCA mutation vary in terms of the origin of their cancer. Cancers arising from the ovary compared to the fallopian tube vary from 75% to 20%, and some even think that all ovarian cancers arise from the tubal epithelium.4 In addition, ovarian cancer is a rare but deadly cancer, and although there is only a 1.5-1.7% lifetime risk of ovarian cancer, the death rate is approximately 50% or higher. This warrants reasonable prophylactic approaches to prevent cancer, particularly in those women at increased risk of ovarian cancer due to a deleterious mutation. In addition, the morbidity from removal of the ovaries in premenopausal women is considerable and is associated with all of the effects of early menopause including osteoporosis, heart disease, and urinary issues. For these reasons, bilateral oophorectomy in premenopausal women is reserved for those in whom the benefit outweighs the risk.
This study was a decision analysis to determine the efficacy and cost of combining vaginal hysterectomy with bilateral salpingectomy. The authors used TreeAge Pro, an interactive database in which researchers input estimates of the rate of complications, readmissions, fallopian tube carcinoma, and effectiveness of the intervention in prevention of cancer. In addition, estimates of the cost of the additional surgery, the cost of treating ovarian cancer, and the cost of complications to balance the effectiveness of the intervention also are considered. The authors used the Falconer study, which was a large population-based study that measured the rate of ovarian cancer in women who underwent hysterectomy, hysterectomy and BSO, BSO, and unilateral and bilateral salpingectomy to estimate the prevention associated with salpingectomy.5 The Falconer study has been criticized because the rate of bilateral salpingectomy was low, the data on oral contraceptive use were not included, and the hazard ratio for ovarian cancer was much lower with hysterectomy and BSO (0.06 at 10 years) than it was for bilateral salpingectomy (0.37 at 10 years). That being said, it gave Cadish and colleagues an estimate of the rate of ovarian cancer with bilateral salpingectomy. Using these data, they estimated that the risk of ovarian cancer was reduced from a probability of 0.01300 to 0.00455, a reduction of 55%, while a hysterectomy with BSO reduced the risk of ovarian cancer to 0.00078, a reduction of 94%.
Cadish et al found that planned salpingectomy was only slightly worse than hysterectomy alone in terms of complications, with a rate of 7.68% in the vaginal hysterectomy alone group and a rate of 7.95% in the hysterectomy with salpingectomy group. The authors estimated that there were three additional complications for each five cases of cancer. Salpingectomy was less expensive than not performing it, even when the cost of cancer care was excluded. They concluded that bilateral salpingectomy at the time of vaginal hysterectomy was a reasonable and cost-effective approach with minimal morbidity. A second study found that salpingectomy at the time of vaginal hysterectomy was feasible in most women and increased the operating time by only 11 minutes and blood loss by 6 mL, both of which are trivial.6
A commentary in the same journal by Kho suggests that it is time for a “policy” regarding salpingectomy at the time of hysterectomy.7 She concluded that given the cancer prevention benefit that results from bilateral salpingectomy and the low morbidity, removal of the tubes at the time of hysterectomy should become standard practice as opposed to just a clinical recommendation.
So, as clinicians, how should we counsel our patients? Bilateral salpingectomy reduces reoperation for benign adnexal surgery from 12.6% to 4.2%.8 This reduction is substantial and is a reasonable rationale for doing bilateral salpingectomy at the time of any hysterectomy. It may reduce the probability of ovarian cancer from 0.013 to 0.00045, about a 55% reduction, suggesting that approximately 55% of the ovarian cancers start in the fallopian tube. The rate of salpingectomy for sterilization has increased from 0.4% to 35.5% from 2011 to 2016. Interestingly, by 2016, salpingectomy was done in 78% of the interval tubal sterilization procedures.9 This is also a reasonable approach, as the efficacy of sterilization is better and the morbidity is not increased substantially.
So what is the risk of routine salpingectomy for cancer prevention? Clinicians may be counseling their patients that it will prevent ovarian cancer. We should be careful about promising cancer prevention when it may provide only about a 55% reduction in the probability of developing ovarian cancer, approximately the same rate as oral contraceptives.
Financial Disclosure: OB/GYN Clinical Alert’s Editor, Jeffrey T. Jensen, MD, MPH, reports that he is a consultant for and receives grant/ research support from Bayer, Merck, ContraMed, and FHI360; he receives grant/research support from Abbvie, HRA Pharma, Medicines 360, and Conrad; and he is a consultant for the Population Council. Peer Reviewer Catherine Leclair, MD; Nurse Planners Marci Messerle Forbes, RN, FNP, and Andrea O’Donnell, FNP; Editorial Group Manager Terrey L. Hatcher; Executive Editor Leslie Coplin; and Editor Journey Roberts report no financial relationships relevant to this field of study.