BackTable / OBGYN / Podcast / Transcript #24

Podcast Transcript: Opportunistic Salpingectomy

with Dr. Rebecca Stone and Kara Long Roche

In this episode, Drs. Mark Hoffman and Amy Park invite Drs. Rebecca Stone and Kara Long Roche to speak about opportunistic salpingectomy to prevent ovarian cancer, specifically serous carcinoma. You can read the full transcript below and listen to this episode here on BackTable.com.

(1) Challenges in Ovarian Cancer Treatment: Detection and Disease Progression

(2) Opportunistic Salpingectomy Procedure Overview and History

(3) Opportunistic Salpingectomy as a Preventative Measure

(4) Salpingectomy Procedure Coding

(5) The Multidisciplinary Nature of Ovarian Cancer Treatment and Prevention

(6) Salpingectomy Technique

(7) Patient Screening and Selection Protocol for Salpingectomy

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Opportunistic Salpingectomy with Dr. Rebecca Stone and Kara Long Roche on the BackTable OBGYN Podcast)

Ep 24 Opportunistic Salpingectomy with Dr. Rebecca Stone and Kara Long Roche

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[Mark Hoffman MD]
Hello, everyone. Welcome to the BackTable OBGYN Podcast, your source for all things Obstetrics and Gynecology. You can find all previous episodes of our podcast on Spotify, Apple podcasts, and on backtable.com.

Welcome back to another episode of BackTable OBGYN. This is Mark Hoffman. Again, I've got with me Dr. Amy Park. How are you, Amy?

[Amy Park MD]
Good, how are you?

[Mark Hoffman MD]
I'm good, just got back from spring break, still trying to get back on working hours. We have great, great guests today. I'm really excited. Thank you for finding our guests today, Amy. We have Dr. Rebecca Stone, an associate professor of OBGYN, and the director of the Kelly Gynecologic Oncology Service at Johns Hopkins. How are you, Becky?

[Rebecca Stone MD]
I'm great. Thanks so much, Mark and Amy, for having us.

[Mark Hoffman MD]
We're excited. We've also got Dr. Kara Long Roche, the Associate Director for the GYN Oncology Fellowship in the Department of Surgery at Sloan Kettering, the Cancer Center, and the section of Ovarian Cancer Surgery. Kara, how are you?

[Kara Long Roche MD]
I'm great. Thank you so much for having us, to both you and Amy.

[Mark Hoffman MD]
This is a topic I'm also personally very curious about, but we're here to have you guys talk about opportunistic salpingectomy. Something that has evolved significantly over the last decade. Before we get into the heart of the topic, why don't we start with you, Becky? Tell our listeners a little bit about you, about your practice, and how you came to be interested in this topic.

[Rebecca Stone MD]
Thanks so much, Mark. I am a GYN Oncologist. I've been at Johns Hopkins now since 2014. A large part of my practice is focused on taking care of women who are diagnosed with ovarian cancer. As you and Amy both know, ovarian cancer is a really challenging cancer to treat. It's an unusual cancer. We can talk about why that has resulted in some problems with screening, and certainly, why we don't have a cure for it.

Both Kara and I spend many days a week taking care of patients who are affected by this cancer, suffer from it, and many who ultimately die. That is really what brought Kara and I to the table. We would do anything to be able to prevent people from ever having to have this cancer.

[Mark Hoffman MD]
Thank you. Kara, tell us a little bit about your practice, and how you got to where you are now.

[Kara Long Roche MD]
I'm one of the GYN Oncologists at Memorial Sloan Kettering Cancer Center in New York City. I'm on Team Ovary, the section of ovarian cancer surgery. My practice is averse but focused primarily on treating patients with ovarian cancer, which as we all know is usually advanced ovarian cancer. I'm focused on surgical treatment. For a lot of reasons, many of which are exactly what Becky said, I'm just desperate to find a way to prevent-- early detection, if we can, but prevent, primarily, this disease.

I'm the daughter of an ovarian cancer survivor. I come from a family that has high risk, and so this has been a research interest of mine. You can call it a personal and a professional passion. I was lucky enough to cross paths with Becky for a short period of time at Hopkins when we both were attendings there together. We realized that our hearts were in the same place, and so we were in this together even though we're at two separate institutions.

[Mark Hoffman MD]
That's great. Again, thank you both for making time. I know you're both very busy, but we value your time greatly. Remembering the show's around an hour, talk to our listeners a little bit about ovarian cancer. When we say ovarian cancer, obviously, that can mean a number of different things. When we're talking about ovarian cancer as it relates to opportunistic salpingectomy, what types of ovarian cancers are we talking about, how common is it? As we've seen in our practice, obviously, it's a bad disease but talk to us specifically about what that means.

(1) Challenges in Ovarian Cancer Treatment: Detection and Disease Progression

[Rebecca Stone MD]
When we think about ovarian cancer, by far and large, you're talking about epithelial ovarian cancer. That comprises about 80% to 90% of ovarian cancers. Then the other small percentage is made up of germ cell tumors and stromal tumors. When we think about epithelial ovarian cancer as a group relative to germ cell and stromal tumors, epithelial cancers really are the most lethal group of cancers. In that group of cancers, you may have heard of cancers like clear cell, endometrioid, mucinous. Then, of course, the most infamous one, high-grade serous ovarian cancer.

High-grade serous ovarian cancer is in the group of epithelial ovarian cancers and is, by far, the most common. It's a very lethal type of ovarian cancer. Somewhere on the order of 20,000 women are diagnosed with that type of cancer in the United States every year. It really is the histologic type of ovarian cancer that we think we have the most chance of preventing with opportunistic salpingectomy.

[Mark Hoffman MD]
What makes it so difficult to treat?

[Kara Long Roche MD]
I think most of us know that there are no symptoms of high-grade serous carcinoma when it is in its early stages or early phases. I think we don't even really understand whether the stage progression is how the disease disseminates, or whether it disseminates immediately to advanced stage, when it's in its early form. There's no symptoms, there's no effective screening tests.

There's been wide-scale, massive studies that have been undertaken to look at screening tools such as ultrasound, CA 125. While there was some signal that we might be able to find it at a slightly earlier stage, that never translated to a reduction in cancer death. What we have is a disease with no symptoms, no screening test, and unfortunately, as we've all seen these patients come in with widespread advanced disease. I think it's still a unique cancer because, even though the cancer is widespread, we do still treat it with curative intent. With some of the newer developments, there are patients who are long-term survivors, and some who are cured.

Unfortunately, the majority of patients undergo hours-long surgery, months and months of chemotherapy, and unfortunately, will still recur and die of their disease. I think it's not so much that the biology of the disease makes the cells resistant to treatment, but that we have no way to find it before it's widely metastatic. That's really what makes it more challenging.

[Rebecca Stone MD]
I just wanted to just say that I remember reading “that” The Gray Journal article that laid out the whole rationale of why ovarian cancer, and I'm doing that in quotes right now, is disseminated tubal cancer. It was fascinating because all of this evolved over the course of my training. Not to date myself too much, but I graduated from medical school in 2002, and it's now 2023. We did all these things like ovarian cancer screening with pelvic ultrasound, and checking CA 125, and then there's the PLCO study. Nothing helped, and actually, we hurt patients by going in and trying to take out these cysts.

[Amy Park MD]
It was such a great article because it laid out the biologic plausibility and rationale for SIN and its existence because nobody really paid attention to the tubes. It was like a passive actor to get the sperm and the oocyte together, do you know what I mean? Can you just tell our listeners a little bit more about that whole journey of understanding? I think that's really crucial. I'm in the stands, but you guys are in the front seats of all these developments. It's a complete change in our understanding, mindset, and paradigm shift. Just tell us a little bit more about that.

[Kara Long Roche MD]
I think Becky should explain it because she does the best job of it. I tell patients all the time that when someone finally looked in the fallopian tube, and realized that this was the origin of serous carcinoma, everything made sense. That's why there's no symptoms, that's why screening doesn't work. This discovery actually made all of those trials of hundreds of thousands of women where screening didn't prevent deaths, it made it all make sense.

[Rebecca Stone MD]
If you really think about it, I agree, Kara. It was like a light bulb. Amy, your point about these screening trials, all these screening trials have been structured around ultrasounds. Things like CA 125, or maybe even some thinking about more sexy blood tests we can do in this day and age. When you really stop and think about it, there's no medical grade imaging that we have that can even see the fallopian tube. I think that it's essentially time that we accept that the biology of ovarian cancer is different from that of other solid cancers.

We've done screening tests in other solid cancers, like cervix cancer and lung cancer, where screening results in a stage shift that is life-saving. That just hasn't been shown to be the case with ovarian cancer. That may be because there really isn't an early hematogenous phase to the cancer where we could pick it up in the blood. The early phase is this widespread dissemination that occurs in the peritoneal cavity and a blood test just is not going to be able to detect that. The history of this is exactly what you say, which is that the BRCA genes were sequenced in the mid-1990s when sequencing was really clunky and hard and expensive. People like Kara and my personal hero, Mary Claire King really led that charge. We're so grateful to her.

Once that was discovered, that really created some biologic rationale for what we know as risk reducing surgery; this idea that you can reduce a high risk patient's lifetime risk of developing ovarian cancer by removing the ovaries. When we take out the ovaries, there's no point in keeping the tube because the person can't get pregnant and the blood supply of the tube and the ovary are heavily intertwined, so the tubes came out with the ovaries. You're right, I think people were really focused on the ovary.

Then one day in the early 2000s, people began looking at the fallopian tube under the microscope. They found that there was a lot of dysplasia and that dysplasia really looked very similar to invasive high grade serous cancer. Then people started to look at larger cohorts of BRCA patients and started to find these abnormalities in the fallopian tubes. Then there was a pile on, lots of scientific data and even epidemiologic data and population data that showed taking out a fallopian tube for ectopic pregnancy or taking out the fallopian tubes for surgical sterilization in large populations of people resulted in a decrease incidence of ovarian cancer.

(2) Opportunistic Salpingectomy Procedure Overview and History

[Amy Park MD]
Even tubal ligation too, which why-- and we'll get into this later, but the literature that I've seen about performing opportunistic salpingectomy, the crucial part is prioritizing the getting the fimbriae-- why would a tubal ligation, just cutting it in half, help?

[Kara Long Roche MD]
It's interesting that in some of these big studies, it may be that the tubal ligation had a greater impact on the endometriosis associated ovarian cancers. The endometrioid and the clear cell that really, their biological origin is endometriosis coming out of the fallopian tubes, landing on the ovary, and then undergoing carcinogenesis and the tubal ligation. In some of the bigger studies, when they really went back and subtyped, it looked like the tubal ligation had the biggest impact on the endometriosis associated cancers, which then even lends a little more strength to the salpingectomy as a population-based prevention strategy. Because you would decrease not only serous carcinoma by removal of the fimbriae but you will also accomplish that blocking of the endometriosis associated processes.

[Amy Park MD]
When would you pinpoint this sea change? I seem to remember around 2017 or something like that. Is that around the time where we all came around?

[Mark Hoffman MD]
I can actually say I came to Kentucky in 2012 and someone close to me said, "I think I'm going to get my tubes out," and this is a person not in medicine. I'm like, "For what?" They said, "I was reading. My aunt had ovarian cancer and I read somewhere about it.” Again, this is not a doctor. I was like, "Oh, that's ridiculous. I would know that. I'm an OBGYN. I just finished training." I called a couple of friends, GYN oncologists, that I knew from training, and they're like, "Actually we're starting to do that." This person that I knew that had brought it up to me was the first person I knew, and that was in 2012, 2013, to get their tubes out. It was like they were the first person to ask their gynecologist to do this surgery.

It was like, boom, and they actually brought it up. I was at a lecture and an ovarian cancer specialist was talking about it. When I brought it up and they looked at me like, "Who do you think you are?" Ovary cancer and the fallopian tubes. It was somebody who had been studying this disease for decades. I think, the next year there was a big update and they had a couple slides back in their talk, but it came out of nowhere for those of us who were doing it. It just feels like it just happened. Obviously a lot of people put a lot of work into it, but I'm curious, Amy's question: what happened? How did this sea change happen?

[Rebecca Stone MD]
If you think back, SGO published recommendations about it first in 2013 and then ACOG put out their first practice bulletin in 2015. That's probably why, Mark, 2017 would have been about the right time. Usually, once a practice bulletin gets out it usually shows up in our recertification for boards. We read it and then by 2017, people are increasingly familiar with it. It was really around that time, not just in the United States, but several professional level societies globally, really began to endorse salpingectomy as a primary prevention strategy for ovarian cancer.

Canada's been a real leader in this, but England, Germany, certainly Denmark, Sweden and Australia. I think there's still a lot of work to be done. Kara and I, we're spending the back end of our lives working on this. But you're right, it really has been over the past couple years that there's been increasing advocacy for it. Amy, to your point, I think why tubal ligation? The other thing I think about a lot is, why the fimbriated end of the fallopian tube? What is the deal with that? When you think about the fimbriated end of the fallopian tube, it's like a hotbed of missense P53 mutations, the P53 being our canonical tumor suppressor gene.

That part of our body is perhaps one of the most P53 mutated organs that we walk around with on the daily. Why is this? It's because, I think, it's just getting attacked by the ovary. The ovaries are ovulating and exploding on it every month. 14 days later when a woman has her period, there's some retrograde menstruation that ends up in the pouch of Douglas. Then the fimbriated end of the tube just sits in there and marinates in all that blood and gets all this free radical damage. It just accumulates these P53 mutations over time.

Anything that we can do to decrease retrograde menstruation, decrease the number and intensity of menstrual cycles, ovulatory cycles. Whether it be pregnancy or breastfeeding or birth control pills, all of these things decrease a person's lifetime risk of developing ovarian cancer. Maybe, in part, due to that mechanism.

[Mark Hoffman MD]
All of these things. Like Amy said, why would tubal ligation matter? We had all these facts that we knew work like birth control pills. We don't really know why, but now we've got this possible explanation that might tie it all together for a disease that some really hard working, brilliant people have been working on. This disease like you said, for a century or more to have a breakthrough like this. I'm not a gynecologist, but it seems like a pretty mind blowing thing to be working on this stuff as it's happening.

[Kara Long Roche MD]
For a disease where we're really still scratching our heads as to how to detect it early, really, the quest for screening tests is still active. Unfortunately, we're not close to having one. This whole tube hypothesis that ties everything together has completely opened the door for prevention options or risk reducing options. It's really wild to see this come to fruition in our careers.

[Amy Park MD]
Can you tell us, what is opportunistic salpingectomy, when do you do it, how do you perform it, when are the opportunities? We're talking about hysterectomy, but my colleagues doing OB are doing it at the time of C-section. More power to them, those veins are like the size of my finger! Tell us a little bit more about it, because I think you have an important view. Then as a follow up to that, I want to ask, when do you think we're going to see the results?

[Kara Long Roche MD]
I'll start by explaining what it is. The concept is that removal of the fallopian tubes will reduce risk. How do we expand access to that option safely? Becky and I always think about it as, let's start with the safest and the most practical approach, which is when a gynecologist or an obstetrician is already there. The opportunities then, when a gynecologist or obstetrician is already there, that's your foundation of opportunity. Instead of tubal ligation at the time of hysterectomy, certainly C-section in someone who has finished childbearing.

Even if you're taking out an ovarian cyst in someone who's completed childbearing, those are all the lowest hanging fruit for when the tube should come out. Right now, that's the situation where we have the most evidence. There's a really robust body of evidence that supports salpingectomy being a safe, feasible and cost effective option in those situations. I'll throw it over to Becky to talk about all the places that we can expand it and where we don't yet have data, but we're working on it.

(3) Opportunistic Salpingectomy as a Preventative Measure

[Rebecca Stone MD]
I think Kara, to your point, that's a large number of people. We're talking about 400,000 women who undergo hysterectomy in this country every year, and 700,000 women who are interested in surgical contraception in tubal ligation. If we, as a field, could really embrace that universally as a chance to counsel women about and provide them with the choice to use those as opportunities. Not just for surgical contraception or hysterectomy, but secondarily as ovarian cancer prevention. I think we have the opportunity to impact many women.

Some of the cost modeling and projections around this suggest, if we universally adopted this and performed this at the time of hysterectomy and in lieu of tubal ligation, you're talking something like 2000 lives you could save per year and half billion healthcare dollars, just with universal uptick in the GYN space.

[Mark Hoffman MD]
Ligature doesn't sound so expensive when you put it in those terms. Right?

[Rebecca Stone MD]
Yes, exactly.

[Kara Long Roche MD]
Not nearly as expensive as all the suffering, and the time, and the surgery, and the chemotherapy, and the drugs, and just the lives lost.

[Mark Hoffman MD]
Right. I have heard OB docs saying, "We don't want to have to open the ligature surgery on the C-sections." I'm like, "So what? This is potentially life-saving!" I love hearing this stuff. This is incredible.

[Rebecca Stone MD]
Yes, I think this is the information that we need to get out there because these are the talking points that we can use on our services and with our hospital. There's a lot that we can do. One thing that we've done at Johns Hopkins is try to negotiate having an energy device in the labor and delivery OR, and negotiating with the energy companies to get the lowest possible cost per unit on energy devices.

One of the companies that we're working with is able to provide us with a refurbished energy device at something like $34 a device. That's really nominal cost. Also, as a time-saver you don't have to-- as Amy, you point out, those veins are so huge and, I think, intimidating.

[Mark Hoffman MD]
There are reusable devices too, not just refurbished. We have a bipolar device that is not disposable that you could certainly use in an open case like that.

[Kara Long Roche MD]
Yes. I think that the other thing, talking about refurbished devices, that's one of the big impacts of healthcare on the environment. Just how much it takes to produce these devices. We had a great talk in SGS by Kelly Wright on sustainability and climate change, healthcare impact on climate change. If we can reuse devices, it's both cost-saving, effective, helps the patient and does not contribute to infections. Now we have the data and lots of meta-analyses. I think, to your point about cost and impact, it's a huge deal to take advantage of these opportunities.

(4) Salpingectomy Procedure Coding

[Amy Park MD]
What do you think the uptick has been? Do we have data on that?

[Rebecca Stone MD]
If you look at the data, you have to take the data, I think, with a grain of salt because there's a lot of challenge in gathering this data. With the way that we currently do billing and coding in the United States, lots of procedures are bundled, like hysterectomy. We don't have an ICD-10 procedure code, actually, that is specific to opportunistic salpingectomy.

We have one for prophylactic salpingectomy, so removal of the tubes for persons who have risk factors like genetics or family history. Right now, the way that we do coding in the United States and how insurance recognizes that, a risk factor of being a woman or having a fallopian tube is not acknowledged. Our coding, actually, is outdated and it's not consistent with the current standard of care.

[Mark Hoffman MD]
There's no CPT code either. The CPT codes that exist, one is sterilization, so it's a bilateral code. It is with transection. ACOG, for a while, was telling us to do that, but it doesn't have nearly as many RVUs as the adnexal laparoscopic-- adnexal code, which is tube and/or ovary, which is a unilateral code associated with pathology and, I think, the vignettes for endometriosis. You're getting a bilateral-- people are billing, and correctly, because it is removing two fallopian tubes, but my guess is CMS will step in and probably demand that we redo those codes.

There is no laparoscopic bilateral salpingectomy for the purposes of sterilization because most CPT codes have to be associated with a diagnosis code. You can't do a cancer surgery diagnosis for someone who's got a broken finger. That has to match up. We're behind on this. This is something I said on ACOG's committee on Health, Economics, and Coding a decade ago and it was something we were talking about even then, but these things take a lot of time. That's how new this is.

[Amy Park MD]
How do you measure the uptake? You're talking about billing data, but are there estimates, at least?

[Rebecca Stone MD]
That's what I'm saying, if you look at the papers on this, you have to look at it with a grain of salt. I think we're doing a pretty good job of performing salpingectomy at the time of hysterectomy, as gynecologists. I've seen estimates as high as 65% to 85% of hysterectomies, but the current data on performance of salpingectomy in lieu of tubal ligation is not nearly as good for some of the reasons we talked about at the time of C-section, but also even at interval surgical sterilization. Some of the data would suggest that we're only at 18% uptake.

[Kara Long Roche MD]
One of the challenging things, and this is part of the reason why this quest is so complicated, is that there's legal implications, or policy, because the laws, state-based laws federal about surgical sterilization, and what Medicaid and Medicare will cover are very nuanced. There are certain states, for example, that don't include salpingectomy as a reimbursable, acceptable, procedure for sterilization.

[Mark Hoffman MD]
I didn't know that. Wow.

[Kara Long Roche MD]
There are physicians in certain states who may not be able to bill for a salpingectomy, or get reimbursed for a salpingectomy for sterilization. This complicated tangle that needs to be untangled is everything from the law, to some outdated policies surrounding sterilization with Medicaid, to the billing, to the coding, and to the databases. One thing that we're trying to do, and, hopefully, are succeeding in doing, is to put salpingectomy into some of the national databases, like NSQIP database, for example.

If we could just include that variable, we would be able to start the collection. We've had to really think about this from this amazingly comprehensive approach. I think Becky and I have thought about things like billing, and coding, and laws, and policy, way more than we ever thought we would have had to as GYN oncologists.

[Mark Hoffman MD]
As I'm thinking about it, hysterectomy, with or without tubes and/or ovaries, given the hysterectomy codes, won't tell you whether it was done--

[Kara Long Roche MD]
No. Someone would have to go check every path report, and that's not a feasible way.

(5) The Multidisciplinary Nature of Ovarian Cancer Treatment and Prevention

[Mark Hoffman MD]
Wow, it's an immense amount of work, for sure, but for something that-- I've heard you guys say-- the way you're describing opportunistic salpingectomy, you're talking about the level of impact in reducing ovarian cancer, similar to HPV vaccines, or even more so. Talk to us about how big of an impact you think this could have.

[Rebecca Stone MD]
Yes, Mark, absolutely. You're like a mind-reader. We're always thinking about, when we think about public health, the number needed to treat. We think it's probably on the order of, or on the magnitude of HPV vaccine; something like 1 in 300, 1 in 500, potentially, and so a very reasonable strategy. We're talking about a cancer, a lethal cancer, that affects 1 in 78 women in their lifetime. A cancer for which we have no screening, we have no cure.

We're able to offer a strategy for prevention, where we remove a structure that has no form or function after a certain time point in a woman's life, after they've completed childbearing, and significantly reduce someone's chances of getting that cancer. Maybe on the order of 65%, maybe even higher.

When you think about just the history of medicine, arguably, we've never really had this opportunity for cancer prevention, ever, where we could remove something that doesn't really have any known value, once they're in their post-reproductive years. I think Kara and I, one of our biggest goals is to expand access to opportunistic salpingectomy outside of the OB/GYN space as well.

When you think about it, hundreds of thousands of people undergo surgeries on their abdomen in their post-reproductive years. When people are in their mid to late 40s, that's when people undergo cholecystectomies, hernia repairs, they have colon surgery, urologic surgery, and appendectomies. We really think that those could be our additional windows of opportunity for ovarian cancer prevention. One of our asks is to our colleagues, to our people in OB/GYN, to start to think about how we might be able to work together as a team, as a surgical community, to make this an option for as many women as possible.

[Mark Hoffman MD]
A true multidisciplinary, multispecialty approach, and multicentered. I think, Becky, you've got a program you guys are starting with this, is that right?

[Rebecca Stone MD]
Yes, honestly, we really started a couple of years ago. We do a lot of multidisciplinary surgery, Kara does too. One of our favorite things is working as a team to help somebody. I was in a multidisciplinary surgery. I was doing a case with colorectal for somebody who was having a colectomy for Crohn's disease. The patient had a very large dermoid. We were addressing that. The patient was something like 48 years old.

We finished the dermoid, and I said, "Oh, wait a minute, I just need to take out the fallopian tubes real quick," and the colorectal surgeon was like, "Why?". I was like, "Oh, because it's a very effective strategy for reducing ovarian cancer risk, now that we know that most ovarian cancers, especially high-grade serous ovarian cancer, probably comes from the tube." Honestly, he almost fell over. He was like, "No one knows about this. If you guys could just educate us about this, we would be interested in helping with this, we're very interested in these things.

Then, gosh, in October, 2021, I was in another multidisciplinary case with urology and I said, "Hey, I know that you guys are moving towards organ preservation for women who are having bladder cancer surgery and you're not taking out tubes and ovaries in the uterus anymore. But we really think that there might be some value to removing the fallopian tubes because that's where a lot of ovarian cancer comes from. Would you guys be interested in helping with that?" They're like, "Yes, yes, of course. That's really interesting."

A year later I ran into one of their fellows and I was trying to convince her to stay at Johns Hopkins and I said, "Hey, if you stay here, you can help us with our opportunistic salpingectomy outside of GYN." She was like, "Oh yes, like taking out the fallopian tubes to prevent ovarian cancer?" I said, "Yes!" She said, "Oh, we've been doing that for the past year." I was like, "Oh, you got to love Johns Hopkins. Tell them something convincing and show them the science and they're all in." That's how this all got started.

[Mark Hoffman MD]
Now the colorectal surgeons are taking out the fallopian tube?

[Rebecca Stone MD]
That's the direction that we're heading. Certainly, urology is already very comfortable with that. Kara and I were approached by a foundation called Breakthrough Cancer, to pick our brains on what we thought might be a game changer in the ovarian cancer space. We were like, "Well we're not really sure about screening and it's really hard to cure once women have widely metastatic and recurrent disease. What if we focused on prevention?" That's where we've come and I’ll leave it to Kara to talk about that big multi-institutional initiative.

[Kara Long Roche MD]
There's this organization that brought us all together called Breakthrough Cancer. It brought together teams from Sloan Kettering, Johns Hopkins, MD Anderson, Dana-Farber, and MIT. They basically gave us the task of, "Tell us what you think is going to change the world." They gave us some individual disease sites to focus on. Becky and I of course were super excited to put together what we thought was going to change the world for patients with ovarian cancer. Of course, our vision is that, by changing the world, these people will never get this cancer.

We've had to really put together a strategy. One, how do we establish the scientific foundation to do this procedure? What data exists already? Where are the gaps in the data? How can we make this equitable and expand access to everyone in an equitable and fair way? Then, and we're always talking about this, how do we make sure that this is done safely and not done in a cavalier way?

We have put a lot of time into putting together the data for what already exists. That is what we talked about before, we know that instead of tubal ligation for sterilization and the time of hysterectomy and in the GYN OR, this should be offered to patients as much as possible in the appropriate patient, but, how can we safely expand this? It's a really hard question, because, let's take all these opportunities where women are having abdominal and pelvic surgeries. Should GYNs be coming into the OR to do these procedures with our general surgery colleagues? Should we be teaching our general surgery colleagues how to do these procedures? How do we teach them how to do it? How do we make patient selection guidelines? How do we make tools to teach patients? For the past few years, we've been putting together basically this entire endeavor.

Again, we hope that when we come out of this we'll have a clinical trial that establishes that it's safe and feasible outside of the GYN OR that we'll have materials to teach patients to teach doctors GYNs and non-GYNs. We'll have selection criteria, we'll have best practice guidelines. By the end of this, we'll be able to really expand access in a safe way. The last thing we want to do is for any patient to be unsafe. That's our first and foremost priority.

[Amy Park MD]
I love that so much. My mind is blown about the multidisciplinary aspect because of the whole concept. I love it that urologists just adopted it right away. They're also so familiar with laparoscopy and specifically robotic surgery and bipolar cautery. Although I will say, and I'm saying this in a loving way, I have walked into the OR and some services have been like, “Is this the fallopian tube?” You're like, "No, that's the round.”

[Kara Long Roche MD]
Or the IP, and these are things that Becky and I have thought about. Because if we tell the world to start taking out fallopian tubes, but there's no appropriate anatomical illustrations. Becky actually went to one of her illustrators at Hopkins, I'm stealing your story from you, Becky, but she was like, "There's no great visual in a textbook of the mesosalpinx. That tubo ovarian ligament, the little ligament at the end that connects the fimbriated end to the edge of the ovary is really well described in most places."

We're like, "If we're going to be telling people to do this, we need accurate teaching tools." Becky actually went and worked with an illustrator to come up with this beautiful illustration that hopefully will come out with some of our published work to describe these structures.

(6) Salpingectomy Technique

[Mark Hoffman MD]
Can we talk about the technique of salpingectomy? That little tiny connection between the fimbriae and the ovary, as we're doing more and more of these. I do loads of salpingectomies, whether it's for sterilization or for hysterectomy, but there's that little bit of the tube that sticks to the ovary. Should we be taking out part of the ovary just to get every little bleb off? Should we be a ablading on top of that? Talk to me about what we know as possible best techniques for taking out fallopian tubes.

[Rebecca Stone MD]
That's part of our work, to create some teaching materials around this. We agree, when you really think about it, we as a field of surgery, of GYN surgeons, we really haven't doubled down on this even as a surgical field. I don't know about you guys, but it's always the left side that seems more sticky. The right side is just generally easier and more free. I don't know what it is about that left side, if it's just because the colon is always just like bumping against it and the fimbriae more likely to be fused on that side or what is the deal. I think that's really just an interesting observation in and of itself. You're right, we often do find the fimbriae, especially on that left side, stuck to the surface of the ovary.

I do think that we have to do due diligence to make sure that we do everything that we can to get those fimbriae off of there, potentially ablate them. Certainly, some people have written about doing a wedge resection of the ovary in that area, very aggressive things. I don't think that we're there yet. I do think this idea that you're only going to partially excise the fimbriae because that's easy to do, is not the right thing. that we should spend some time dissecting them off with monopolar scissors or what have you.

Then I just, to make the point, that I think we're going to learn more as we do this, as we really study this in a scientific way altogether. I think Canada's really doing a tremendous amount of work on this and one thing that really helped this mission out is the publication that came from some of our colleagues up in Canada who've been following thousands of women prospectively after opportunistic salpingectomy done at the time of hysterectomy or in lieu of tubal ligation.

What they found is that it does substantially decrease the incidence of high-grade serous cancer, but the impact that will have on mortality, we need some more years of follow-up. Right now, I think the message is that we've got to start getting the word out, making sure we all are on the same page. We should counsel patients about this and give them choices about this and look for as many opportunities as we can to offer this safely. Then we desperately need education materials and standardization.

[Amy Park MD]
Like for BRCA risk-reducing salpingectomy. I know that I don't really do them, I don't give those kinds of referrals. Since I'm URO/GYN, however, I remember people talking about best practices and going all the way to the cornu and then really getting pretty aggressive about taking every single little bit of the tube. The conversation that I have observed about opportunistic salpingectomy has not been as aggressive surrounding all of the tubes. Can you guys expound on that and tell me, from your expert opinion, what's the best practice?

[Kara Long Roche MD]
From just a surgical technique perspective, we discussed the fimbriated end and how challenging that is to get off. Of course, we always discuss in our ORs with our fellows, the one big mistake you can make when you're dissecting the fimbriae off is accidentally taking part of the IP if you go down a little bit too low.

On the other side, when you get to the uterine cornua, it's really diminishing returns when you are going and trying to dissect out the interstitial portion of the tube from the uterus. We don't generally recommend doing that because really, these cancers are fimbriated end cancers. I think when we translate that to the concept of opportunistic salpingectomy, one of the things that we always talk about is: when do we tell people to stop? If there's bad adhesions, should we be telling people to abandon the procedure? Probably the answer is yes because as a risk-reducing procedure in a patient at average risk, we really want to mitigate the potential harm.

For this procedure, certainly getting all the fimbriated end off of the ovary is important, but probably not the situation to do a big wedge resection or dive deep into the ovary. At this point the harm is going to start outweighing the potential benefit. Same thing with excising the interstitial portion of the tube and the uterus, probably not worth that risk. Same thing if there's bad adhesion, somebody has bad diverticular disease and the left colon is sticking that tube down. Maybe that's the case that doesn't get the risk-reducing surgery.

These are things that Becky and I are incorporating into our research when we survey other doctors and surgeons and try to identify guidelines for best practice. I think for opportunistic salpingectomy, it's really where you want to limit potential harm.

[Rebecca Stone MD]
Remembering you can always go back. If that fallopian tube comes out, I think it's also important to label which side you took it out, left or right, for this reason. Once you take it out the pathologist, and we could talk for an hour about this, about the limitations of our histopathologic diagnosis of fallopian tube pre-cancerous. If a STEC is found or pre-cancer is found, you always have that opportunity to go back. Doing something very aggressive when talking about something that you might find in 1 in 500 women doesn't make a whole lot of sense, especially I think as we move towards improving diagnostics.

[Mark Hoffman MD]
Are we looking closely enough at the tubes? I'm taking out all these tubes. I'm sure you guys, as oncologists, are going to say no, and the pathologists are like, "Yes, it's fine."

[Rebecca Stone MD]
Oh no.

[Kara Long Roche MD]
Hey, how long do you have for an answer?

[Rebecca Stone MD]
I know! I mean I spent an hour on the phone with one of our pathologists on Saturday about this because I basically was like, "I've heard that maybe we look at 1% or less of a fallopian tube histopathologically." We sat there and went through the math, of the huge surface area of the fimbriated end. Many places will just bivalve the tube and look at one section from each side of the tube and the fimbriated end. It's probably honestly looking at only one star in a galaxy is like what fraction of the fallopian tube we're actually looking at.

That's why we have this collaboration with MIT as part of our breakthrough cancer work to innovate diagnostics. In this era of molecular imaging, why can't we take a whole organ out, label it and look at it with special imaging to really target areas where there are abnormalities and focus on those areas as opposed to just randomly sectioning an organ and hoping we find the area of interest?

[Amy Park MD]
That happened to me. I had somebody I did a cervicopexy on, I took out her tubes. A year later she comes back with disseminated ovarian cancer. They looked back at the tubes later and it was there. Then the other thing I will say in terms of best practices is, how about taking out a uterus and then taking out the tubes and then the pathologist calls you and says, "We didn't find the tubes." I was like, "Is this for real, are you punking me? What's going on?"

[Mark Hoffman MD]
It took me one time for that to happen. Like, "Oh we never got tubes." Now I do left tube, right tube.

[Amy Park MD]
That's what I do too.

[Mark Hoffman MD]
We take out the tubes separately from the uterus. We always take out the tubes first in the hysterectomy, then we do the rest every time and we get down all the way to the little blebs.

[Amy Park MD]
I do that too, I agree, Mark. It happened to me twice and I was like never again, because I know what happens. The pathology tech sections the specimen and then they prepare the side and then they didn't catch the little piece that I got and labeled, 'tube'. I also send them in as separate specimens. Because sometimes I'll get the pathology report and I'm like, "This is incorrect and this is like the gospel." Also, I just wanted to circle back, and can you tell people what STEC is?

[Rebecca Stone MD]
Yes, STEC is essentially like stage zero or ENCI 2 cancer. It's the tubal equivalent to CIN 3 for instance, we think. I think we have a lot to learn about STEC. I think there's probably a very wide spectrum of STEC. There's probably some bad-acting STECs and there's maybe some more friendly STECs. As we do really come to understand STEC biology, which is part of this project, the science part of this project. I think we're going to learn a lot more about them.

(7) Patient Screening and Selection Protocol for Salpingectomy

[Mark Hoffman MD]
I've been doing this now for a decade. I don't think I've done a tubal banding or a clip in probably a decade. Every single hysterectomy, the tubes come out. I've also talked to some other senior surgeons over the years and as this was starting up, they're like, "Wait till you see the damage to the ovary and other things." Can you talk about other possible risks? We talked a little bit about the surgical risks, but are there any downsides for a 30 year old woman who's done having kids and wants it out to the ovaries, to ovarian function, to menopause coming early, things like that?

[Kara Long Roche MD]
I'm happy to answer this. I think that the question has been raised in many different instances of whether removing the fallopian tube somehow damages the vascular supply to the ovaries, which could then damage ovarian reserve and ovarian function and result in early menopause. There are some anecdotal reports of this. There have been many studies, some of them prospective studies, some of them retrospective that have looked at the incidence of menopausal symptoms after salpingectomy or looking at hormonal signals, AMH.

I would say that the overwhelming summary of the data is that salpingectomy does not damage ovarian function and does not result in early menopause. However, I do think that if salpingectomy is done correctly, it will not impair ovarian function. Which leads me to actually, what I think is one of the major potential pitfalls that we have to think about, which is one, how do we make sure that people are doing this procedure correctly? It goes back to your questions about technique.

I do think that someone who's not familiar or comfortable operating around the adnexa and around the IP could potentially damage the IP in taking the fallopian tube out. That, we know, could damage the ovary, especially if they're having a concurrent hysterectomy. Then I think that one thing, and Mark, maybe this isn't what you were asking, but for Becky and I who are thinking about how to expand this in a population, how do we make sure that patients aren't becoming sterilized before they're ready? We know that in this country there's a very dark history of sterilization practices in patients, especially in vulnerable patients.

How do we make sure that if we put this message out there that patients are not having this procedure done before they're absolutely ready? How do we make sure that patients are getting educated, providers are getting educated and we're teaching providers how to communicate this to patients, ensuring that they're done with childbearing. I think, yes, ovarian function, but more than that is making sure that it's being done in the appropriate patient.

[Mark Hoffman MD]
That's such a great point. That's such an important point.

[Amy Park MD]
I was going to also ask, you had alluded to the Canadian data on decreasing the incidence of ovarian cancer by performing opportunistic salpingectomy, I'm assuming that people get the majority of their hysterectomies 40 to 60 or whatever, and then that overlaps with the ovarian cancer incidents. We would anticipate, maybe, a 10-year timeline of when you would see the incidents decrease.

[Rebecca Stone MD]
I think that's probably right. I think that when they published that data in February last year, there was just a short follow up of a few years for a large portion of those patients. I think all of us are really interested in seeing the longer term follow up data, not just in terms of mortality, but also confirming that. It really does decrease population-level incidents of high grade serous cancer. Also going back to earlier in our conversation, we're also interested to know what happens to the other histologic subtypes of ovarian cancer. Does it also decrease endometrioid and clear cells? What about mucinous cancer? We still have no idea where mucinous ovarian cancer comes from.

[Kara Long Roche MD]
This question, we look at the timeline, we said 2013 and 2015 were when ACOG and SGO put out their guidelines. We're really just coming up on a decade of this being done in this country. There is an immense amount of data that I think will come out. Maybe it will not be the end-all, be-all answer, but will, at least shed some light on looking at how often we find high-grade serous carcinoma in someone who's had these procedures. We know even after bilateral salpingo-oophorectomy that you can still get high grade serous carcinoma. Now as we're doing these operations younger, I think in the next 10 years, we're going to learn much more.

[Rebecca Stone MD]
Yes, I think to your point, Kara, it probably will matter at what time in a person's life the procedure is performed. Going back to what we were saying about the fallopian tube accumulating all this P 53 mutation burden in the fimbriated end, the earlier it's performed-- as opposed to like you think about the bladder cancer patient population, I was talking about, neurology, those women are 60 to 70 years old. They've had their fallopian tubes for a long time. They probably have a higher P 53 mutation burden, maybe even a higher number of precancerous lesions.

Really I think if we're going to really maximize the benefit of salpingectomy, probably, it's performing it in women in their 40s, before those fallopian tubes have hung around and had a chance to develop pre-cancerous change. We actually think now that from the time that a pre-cancer forms in the fallopian tube, like a STEC serous tubal epithelial carcinoma, there may be as much as 7 to 10 years before a patient develops clinical symptoms and diagnosis of high-grade serous cancer, as we know it now. There is a time where the disease can be intercepted.

[Mark Hoffman MD]
To follow that up, do you expect that this will evolve and that this will become more than opportunistic? I do a lot of laparoscopy, I do a lot of super complex stuff but also the easy ones are getting in and out of the belly, that's the risk, but once you're in, the risk of major injury from these surgeries is very low, especially in the hands of experienced high-volume surgeons. Is this something that you think will become indicated for everybody? Certainly, BRCA patients, there are high-risk patients, but for the general population, where do you see that going?

[Kara Long Roche MD]
It's actually interesting because there's been a lot of press in the lay media and the New York Times and the Washington Post where some statements have been made advocating for this without too much explanation to follow. Becky and I have both had a huge influx of phone calls to our practices asking just for salpingectomies without any other indicated surgery going on.

I hesitate to say that I think that will become standard practice, because, I do think, anyone who does a lot of surgery knows that surgery is serious business. Even minor surgeries can have major complications, whether they be blood clots or bleeding or infection. I think that we are a long way from telling people to call their doctor and ask for surgery in the setting of average risk.

I think we have so much work to do in the OBGYN OR, to make sure that this is being done all the time. Then we have all these other opportunities that we need to safely expand access in. Only after that can we think about this as a standalone procedure. I hesitate to say I think that's going to happen but maybe. Maybe if we really show that this is preventative, then it will be a safe option, but I think we're far from there.

[Rebecca Stone MD]
I do think one scenario where we may see practice change is that, we know that for high-grade serous cancer, about 20% of it is related to hereditary gene mutation, like BRCA for instance, Lynch, RAD 51, CD, PALB2. That means that 80% of it, we haven't been able to really identify the genetic underpinning. Maybe we'll learn more about genetics, maybe we won't. But that means that the patients that Kara and I take care of, these patients have sisters, they have daughters who have been with us in taking care of these women for 5, 10 years. Who've been at the bedside when they died, and the genetic testing is negative.

Yet we know that if you look at the data on these people who have a family history of a first or second-degree relative who had ovarian cancer, they have a bit elevated risk compared to the general population, in lifetime risk. For them to be able to do something that might decrease their risk of having what their mom had or their sister or what have you, really is very significant. That they can make a decision, that they can take control, that they can do something that is preventative.

I have several of these families and patients in my practice and it's very meaningful to them. I do think that this is one pocket where we may be able to, or we have opportunity to change practice and potentially affect or impact, positively, not the highest risk patients who are at genetic risk but patients who have some increased risk, who have watched or been with a family member who died of it.

[Kara Long Roche MD]
I couldn't agree more with that. I think that strong family history of ovarian cancer or ovarian cancer in a first-degree relative, these patients don't fit anywhere in the guidelines neatly. We tell them they probably have a higher risk, maybe up to 5% of their lifetime and yet there's no place where they fall and I totally agree that salpingectomy as a standalone procedure may be the perfect middle ground for these patients to act on risk reduction without the supply of a premenopausal BSO.

[Mark Hoffman MD]
That's fascinating. You've answered a lot of my questions that I've been thinking about for a long time on this because this is something that, it's new in this world. We've all been through OBGYN residency and Waldo Fellowship, but we know ovary cancers just, it's been this big beast, that's been this big thing that has left so much sadness in its wake and loss. To think that there's actual hope with this disease is very powerful.

Thank you for the work that you guys are doing. Thank you for sharing your work and coming on BackTable OBGYN and advocating for these patients and for women and people with fallopian tubes because, honestly, this is something that needs to be known far and wide, not just in the OBGYN world. Outside and anyone else who spends time in the pelvis needs to know about this. I'm so grateful that you guys were on and thank you so much for your time.

[Amy Park MD]
Thank you.

[Rebecca Stone MD]
Thank you for having us guys and helping us get the word out. We're really grateful.

[Kara Long Roche MD]
Thank you for what you all do. This is a great resource for so many of us.

[Mark Hoffman MD]
Thanks so much. Have a good night.

[Amy Park MD]
Good night guys.

[Mark Hoffman MD]
Thank you so much for listening. If you haven't already, make sure to follow the podcast, rate it five stars and share with a friend. If you have any questions or comments, direct message us at _BackTableOBGYN on Instagram, Twitter, or LinkedIn.

Podcast Contributors

Dr. Rebecca Stone

Dr. Rebecca Stone is an Associate Professor of OB/GYN and Director of the Kelly Gynecologic Oncology Service at Johns Hopkins.

Dr. Kara Long Roche

Dr. Kara Long Roche is the Associate Director for GYN ONC fellowship in the Dept. of Surgery at Memorial Sloan Kettering Cancer Center in the section of ovarian cancer surgery.

Dr. Amy Park

Dr. Amy Park is the Section Head of Female Pelvic Medicine & Reconstructive Surgery at the Cleveland Clinic, and a co-host of the BackTable OBGYN Podcast.

Dr. Mark Hoffman

Dr. Mark Hoffman is a minimally invasive gynecologic surgeon at the University of Kentucky.

Cite This Podcast

BackTable, LLC (Producer). (2023, June 1). Ep. 24 – Opportunistic Salpingectomy [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.