Dr. Sarah Finlayson (biography and disclosures)
What I did before
When I was in training as a gynecologic surgeon, I was taught how to do a “proper” hysterectomy and “proper” tubal ligation. I practiced until I had mastered it. By surgical convention, when we did a hysterectomy and planned to leave the ovaries in situ (in pre-menopausal women); we left the fallopian tubes inside the patient too. At the time of tubal ligation, we clipped or burned the tube and left it inside the patient.
What changed my practice
High grade serous cancer of the ovary represents about 2/3rds of the cases of ovarian cancer that we see. These cancers are often diagnosed at an advanced stage. While this cancer usually responds to initial treatment, it frequently recurs and is not curable in the majority of patients. A growing body of knowledge reveals that the majority of cases of high grade serous “ovarian” cancer actually are fallopian tube cancers. The precursor lesions begin in the fimbriated end of the fallopian tube and the cancer spreads from there. This knowledge about the true origin of this devastating cancer completely changed my surgical practice.
What I do now
I now advise patients to consent for removal of the fallopian tube at every single hysterectomy. Family Physicians can advocate for their patients to ensure the fallopian tube is removed at hysterectomy and tubal ligation. My hope is that by removing the fallopian tube we will prevent many cases of this terrible disease. As a gynecologic oncologist, the majority of my patients already have cancer. The potential for a major impact in ovarian cancer prevention rests with general gynecologists—who perform the vast majority of hysterectomies and tubal ligations. Hysterectomy and tubal ligation are among the most common surgeries that a woman will undergo in her lifetime. This September 2010, the Ovarian Cancer Research Program of BC, launched a province-wide educational initiative aimed at every gynecologist in BC. We are asking gynecologists to remove the fallopian tube at hysterectomy. We are also requesting removal of the fallopian tube at tubal ligation, when a patient requests permanent contraception. I believe these simple changes in surgical convention hold the promise of preventing future cases of “ovarian cancer”.
For more information: www.ovcare.ca
References: (Note: Article requests require a login ID with the BC College of Physicians website or with UBC)
1. Przybycin CG, Kurman RJ, Ronnett BM, Shih IM, Vang R. Are All Pelvic (Nonuterine) Serous Carcinomas of Tubal Origin? Am J Surg Pathol. 2010 2010 October; 34(10): 1407-16. (View article with CPSBC or UBC)
2. Salvador S, Gilks B, Köbel M , Huntsman D, Rosen B, Miller D. The fallopian tube: primary site of most pelvic high-grade serous carcinomas. Int J Gynecol Ca 2009;19:58-64 (View article with CPSBC or UBC)
3. Crum CP, Drapkin R, Miron A, Ince TA, Muto M, Kindelberger DW, et al. The distal fallopian tube: a new model for pelvic serous carcinogenesis. Curr Opin Obstet Gynecol 2007;19(1):3-9. (View article with CPSBC or UBC)
4. Kindelberger DW, Lee Y, Miron A, Hirsch MS, Feltmate C, Medeiros F, et al. Intraepithelial carcinoma of the fimbria and pelvic serous carcinoma: Evidence for a causal relationship. Am J Surg Pathol 2007;31(2):161-9. (View article with CPSBC or UBC)
5. Lee Y, Miron A, Drapkin R, Nucci MR, Medeiros F, Saleemuddin A, et al. A candidate precursor to serous carcinoma that originates in the distal fallopian tube. J Pathol 2007;211(1):26-35. (View article with CPSBC or UBC)
6. Crum CP, Drapkin R, Kindelberger D, Medeiros F, Miron A, Lee Y. Lessons from BRCA: the tubal fimbria emerges as an origin for pelvic serous cancer. Clin Med Res 2007;5(1):35-44. (View article with CPSBC or UBC)
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good confirmation of the knowledge that was passed down to me during residency by general gynecologists i worked under.
I believe that a lot of this research was done at UBC? Well done!! I’ve been recommending it to patients since reading the original press release in September, 2010. Ovarian cancer is a devastating disease and often we feel so powerless to prevent it. Now – what about prophylactic fallopian tube removal in women at high-risk for ovarian cancer?
I am not a gynecological surgeon, but now I understand why the tubes were removed at premenopausal hysterectomies.
I was aware of this new knowledge, and this changed my practice e-mail has reinforced the information. I now discuss this knowledge with all of my patients that are referred to a gynecologist for tubal ligation or any gynecologic problems that might lead to hysterectomy.
I am aware of this issue and have been promoting removal of fallopian tubes
Interesting piece of information
this is interesting.
Fascinating homegrown research! Kudos to the researchers at the BCCA
good news
Useful and informative. I’ll definitely bring it up if a patient is considering hysterectomy.
I am not yet convinced that this is good practice. I appreciate the benefits (redution in the risk of ovarian cancer – a disasterous but relatively uncommon condition). But there is no discussion regarding the risks of prophylactic salpingectomy. We have all witnessed the generous vascular connections between the fallopian tube and the ovary, which can be compromised at the time of salpingectomy (witness the thermal injury spread at the time of cauterization). We may be inducing a premature ovarian failure (menopause). And this may increase the overall risk for cardiovascular disease – a much more serious health riosk for women. Before I change my practice pattern, I need to know both the benefits and the risks to properly counsel my patients about options. I need good evidence (not theoretical evidence) that there is true benefit and no associated risk.
Always wondered why we leave cancer catchers in. Reasonable to consider risk of to ovaries?
One of the clearest change of practice guidlines yet
very useful information. very practical and has totally changed the way i counsel patients who wish to undergo sterilization.
Agree.
Many thanks on an amazing progress on ovarian cancer research.
Fimbriectomy could be an alternative if there are doubts of POF risks.
Would appreciate a comment on tubal ligation as well as it is a big group of our patients in a gynecological office.
High grade serous cancers spread by budding off from the primary tumor site, now often found by our pathologists to be in the fallopian tube, first to the ovaries, then soon after to the pelvis and upper abdomen, when it no longer deemed curable. It is silent spread. I regulary attend our gyne tumor conference, and our pathologists are very good at finding what we believe to be the primary source of serous carcinoma in one of the fallopian tubes, now that they look for it routinely.