The name doesn’t exactly help. But before we discuss rebranding, a brief introduction to the concept . . .
Salpingectomy refers to surgical removal of one (unilateral) or both (bilateral) fallopian tubes. It is thus a surgical option for female sterilization—but also drastically reduces a woman’s risk of ovarian cancer.
This is huge. Ovarian cancer (OC) is the most common cause of reproductive cancer death and the fifth most common cause of overall cancer-related death among women. In the United States, a woman’s overall lifetime risk of being diagnosed with ovarian cancer is 1 in 75, and her chances of dying from it are 1 in 100. The American Cancer Society estimates for 2018 about 22,440 new diagnoses will be made this year, and 14,080 deaths attributed to it. Ovarian cancer is not usually detected until it is too late to effectively treat, and screening procedures have not improved in line with those for other types of malignancies, such as cervical, breast, and colon cancers. Moreover, the overall survival rates for women diagnosed with the disease have not improved much since the 1980s.
Sure, there are other ways to reduce one’s risk. Giving birth, for instance, is associated with reduced OC risk, with a single term pregnancy reducing risk 30-60% relative to nulliparous women and each additional term birth decreasing risk by a bit more. Better protection, particularly against the most lethal subtypes, is offered by the long-term use of oral contraceptives. But the best protection appears to be provided by surgery: hysterectomy alone reduces OC risk by 21%, bilateral tubal ligation by 28%, unilateral salpingectomy by 29%, and bilateral salpingectomy by an astonishing 65%.
A little over a decade ago, it was discovered that most “ovarian” cancer actually originates in a fallopian tube and subsequently spreads to one or both ovaries. The initial findings came from post-operative examination of tissues that had been prophylactically removed from women at elevated genetic risk for OC and other reproductive cancers. More recently, it has been confirmed that the most lethal and most common type of OC, high-grade serous ovarian carcinomas, start as tubal lesions, even in women without a BRCA mutation. This subtype is responsible for 90% of all OC-related deaths.
This brings us to opportunistic salpingectomy: the surgical removal of a woman’s fallopian tubes as a means of preventing OC during pelvic surgery for another indication, such as hysterectomy or tubal sterilization. As evidence accrued that the true origin of OC was in the fallopian tubes, the American College of Obstetricians and Gynecologists issued a formal recommendation that surgeons performing hysterectomies and tubal ligations consider removing both tubes during the former procedure and in place of the latter procedure, even in women of normal OC risk.
A commentary published in Obstetrics and Gynecology in 2014 pointed out that salpingectomy would likely be preferred by patients over ligation for tubal sterilization simply because the former is more effective in terms of preventing pregnancy: “We should not have started thinking about salpingectomy for female sterilization only once a decrease in ovarian cancer risk became part of the equation…If we had included the patient in the discussion, perhaps the higher efficacy of salpingectomy would have been what women desired all along.” One out of every 200 [pdf] women who undergo standard tubal sterilization will become pregnant within a year.
Female sterilization is the most common method [pdf] of birth control in the world. It is the second most common method in the United States and by far the most common method used among older women, used by nearly one-third of women [pdf] aged 35-44. It seems clear that bilateral salpingectomy should replace other methods of female sterilization as a standard practice. It is nearly fail-proof as a method to prevent pregnancy (just one case [pdf] of pregnancy following bilateral salpingectomy has been reported in English language literature), and it bears repeating: salpingectomy reduces OC risk by 65%. It is also surgically no riskier than tubal ligation [pdf], requires just a few additional minutes of time, and eliminates the risk of tubal pregnancies altogether.
A recent piece in Gynecologic Oncology reported that, in addition to the lives saved by reducing OC risk, opportunistic salpingectomy is likely cost-effective. That is, performing the procedure as an alternative to standard tubal sterilization, or in addition to hysterectomy, would prevent a sufficient number of ovarian cancer cases to save money in the long-run. The authors estimate that performing salpingectomy during laparoscopic hysterectomy on a hypothetical cohort of 50,000 women ages 45 would save nearly $24 million in total health care costs. The authors similarly reported a hypothetical incremental cost-effectiveness ratio of $31,432 per quality-adjusted life year for replacing tubal ligation with bilateral salpingectomy for sterilization.
So why am I just hearing about opportunistic salpingectomy, and why are they still “tying” tubes? As I mentioned in the beginning, the name is not exactly catchy. I suggest adopting the term “tubal removal,” consistent with, but a progression from, “tubal ligation.”
Wide-scale changes in medical practice are notoriously difficult to achieve, even when ample evidence exists that current practice should evolve. I find it deeply dissatisfying that we would rely solely on surgeons to make the decision, though. At a bare minimum, patients themselves must be included in the conversation.
Barbie Zabielski