National guidelines on removal of the fallopian tubes, at the time of gynaecological or abdominal surgery, for women who have completed their families, should be considered to reduce the incidence of ovarian cancer, says a new Scientific Impact Paper (SIP) published today by the Royal College of Obstetricians and Gynaecologists (RCOG).
SIPs are produced by the Scientific Advisory Committee at the RCOG and are up-to-date reviews of emerging or controversial scientific issues of relevance to obstetrics and gynaecology.
Cancers which start in the surface layer covering the ovary, known as epithelial ovarian cancers (EOC), are the leading cause of death from gynaecological cancers among women in the UK. High grade serous ovarian carcinomas (HGSOC) are the most common type and most deaths are attributed to it. The main risk factors for EOC are advancing age and a family history of the disease.
There has been little improvement in survival from EOC. The overall survival at 5 years is 43%. However, if the cancer is confined to the fallopian tube or ovary, survival can be as high as 80–95% at 5 years. Surgery and chemotherapy remain the main treatment methods.
The site of origin of HGSOC has been the subject of debate for many years. The very poor survival in patients with HGSOC demands a drive to identify the site of origin and develop new ways for preventing this disease. There has been a growing body of evidence supporting the fallopian tube as the site of origin of HGSOC and this paper reviews the evidence and current understanding around it.
From studying the ovaries and fallopian tubes removed from women at high risk of ovarian and breast cancer, such as women who carry the BRCA 1 mutation, studies have identified a strong link suggesting HGSOC originates in the fallopian tubes. These fallopian tube abnormalities are also very occasionally seen in women at low risk of developing HGSOC.
The opinion paper states that in high-risk women with an identified BRCA mutation, removal of the ovaries and fallopian tubes (bilateral salpingo-oophorectomy) offers the greatest risk reduction for ovarian cancer and a significant risk reduction for breast cancer.
Removal of the fallopian tubes during surgery for other conditions carries minimal additional surgical risk to the patient. However, more research is needed in this area looking at the effectiveness of removing the fallopian tubes in preventing ovarian cancer in high or low-risk women as currently there is no evidence from randomised controlled trials.
The paper concludes that for women who are not at high risk for BRCA mutation and have completed their families, national guidelines for removal of the fallopian tubes as a preventative measure, with conservation of the ovaries, at the time of gynaecological or other abdominal surgery should be carefully considered.
Dr Ian Harley, Consultant Gynaecological Oncologist, Northern Ireland Regional Oncology Centre, Belfast, FRCOG, and lead-author of the paper, says:
“Being proactive and if the opportunity arises among women who have completed their families, removal of the fallopian tubes could help reduce the incidence of ovarian cancer.
“Much evidence supports the theory that ovarian high-grade serous carcinomas arise from the fallopian tube and we now know much more about the genetic makeup. It is necessary to study this group of carcinomas as a separate distinct group and this in the future should lead to improved clinical outcomes for women.”
Dr Sadaf Ghaem-Maghami, Chair of the RCOG’s Scientific Advisory Committee, says:
“Ovarian cancer affects more than 6,500 women in the UK each year and is the fifth most common cancer among women.
“The identification of the fallopian tube as the origin of high-grade pelvic serous carcinomas has the potential to have significant clinical impact on the reduction of mortality associated with ovarian cancer.
“Ongoing epidemiological studies are needed to add strength to the current research which will lead to future changes in surgical practice.”
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About RCOG Scientific Impact Papers
RCOG Scientific Impact Papers (formerly SAC Opinion papers) are produced by the Scientific Advisory Committee. They are up to date reviews of emerging or controversial scientific issues of relevance to obstetrics and gynaecology, together with the implications for future practice. These documents have been rebranded to raise awareness of the issues in obstetrics and gynaecology discussed in the documents and to more accurately reflect their content and remit of the Committee.