ONCOLOGY

Opportunistic salpingectomy: uptake, risks, andcomplications of a regional initiative for ovarian cancerpreventionJessica N. McAlpine, MD; Gillian E. Hanley, MA, PhD; Michelle M. M. Woo, PhD; Alicia A. Tone, PhD; Nirit Rozenberg;Kenneth D. Swenerton, MD; C. Blake Gilks, MD; Sarah J. Finlayson, MD; David G. Huntsman, MD;Dianne M. Miller, MD; for the Ovarian Cancer Research Program of British Columbia

OBJECTIVE: The purpose of this study was to assess the uptake andperioperative safety of bilateral salpingectomy (BS) as an ovariancancer risk-reduction strategy in low-risk women after a regionalinitiative that was aimed at general gynecologists in the province of

sfrom 2008-2011 whowith and without BS or

P< .001) and BS for sterilization (10 minutes; P< .001) compared withhysterectomy alone or tubal ligation, respectively. No significant differ-ences were observed in the risks of hospital readmission or bloodtransfusions in women who underwent hysterectomy with BS (adjusted

; 90.

(aOR, 0.8; 95% CI, 0.56respectively). From 2008performed by open laparotomy decreased from 77-44% with uptake in

ge

nen

icrs

Research www.AJOG.orgClick Supplementary Content underCancer Agency; School of Population and Public Health, Child and Family Research Institute, University of British Columbia (Dr Hanley); Division ofGynecologic Oncology, Princess Margaret Cancer Center (Dr Tone); and Center for Translational and Applied Genomics, BC Cancer Agency (DrsWoo and Huntsman and Ms Rozenberg).

Received Oct. 21, 2013; revised Nov. 8, 2013; accepted Jan. 7, 2014.

Supported by the Vancouver General Hospital and University of British Columbia Hospital Foundation and the British Columbia Cancer Foundation.

The authors report no conict of interest.

Presented in part at the 18th InternationalMeeting of the EuropeanSociety of Gynecological Oncology, Liverpool, England, UK,Oct. 19-22, 2013, and the34th Annual General Meeting of the Society of Gynecologic Oncologists of Canada, Calgary, AB, June 14-15, 2013.

Reprints: Jessica N. McAlpine, MD, Department of Obstetrics andGynecology, Division of Gynecologic Oncology, 6th Floor, 2775 Laurel St., Vancouver,BC Canada V5Z 1M9. jessica.mcalpine@vch.ca.

0002-9378/$36.00 2014 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.2014.01.003

See related editorial, page 385

the article title in the online Table of ContentsRESULTS: There was an increase in the uptake of hysterectomy with BS(5-35%; P< .001) and BS for sterilization (0.5-33%; P< .001) over thestudy period, particularly in women 225,000

women will experieand 140,000 wom

From the Department of Gynecology and Obstetrics Division of Gynecolog(Dr Swenerton), and Department of Pathology and Laboratory Medicine (DVIDEOapproach does not increase the risk of operative/perioperative com-plications and appears both feasible and safe.

Key words: educational campaign, ovarian cancer, prevention, safety,salpingectomy

ctomy: uptake, risks, and complications of a regional initiative for ovarian cancer

ce ovarian cancer,will die of the

disease.1 There are no effective screeningtests,2-6 and, in the past 30 years, ad-vances in treatment have yielded mar-ginal differences in overall survival.7,8

Oncology (Drs McAlpine, Finlayson, and Miller), Department of MedicineWoo, Huntsman, and Gilks) at the University of British Columbia and BCbilateral salpingo-oophorectomy or who underwent surgical steriliza-tion by means of BS or tubal ligation. Parameters that were examinedinclude patient age, operating time, surgical approach, indication,length of hospital stay, and perioperative complications.

laparoscopic, vaginal, and combined procedures (P < .001).

CONCLUSION: After our 2010 educational initiative, there has been ashift in surgical paradigm in our province. This cancer preventionevaluated 43,931 women in British Columbiaunderwent hysterectomy that was performedBritish Columbia, Canada.

STUDY DESIGN: This population-based retro pective cohort study

odds ratio [aOR], 0.91aOR, 0.86; 95% CI,MAY 2014 Ameri5% confidence interval [CI], 0.75e1.10; and67e1.10, respectively) or BS for sterilizatione1.21; and aOR, 0.75; 95% CI, 0.32e1.73,-2011 the proportion of hysterectomies with BScan Journal of Obstetrics& Gynecology 471.e1

Research Oncology www.AJOG.orgEpithelial ovarian cancer is recognizednow to encompass 5 distinct diseases thatdiffer in histologic appearance, clinicalpresentation, response to therapy, likeli-hoodof recurrence,molecular aberrations,and site of origin.9,10 High-grade serouscancer is the most common histologicsubtype; the belief is that most of thesecancers originate in the distal fallopiantube.11-18 In addition, the fallopian tubelikely plays a permissive role in the devel-opment of the next 2 most common sub-types, endometriosis-associated clear celland endometrioid ovarian cancers, whichserve as conduits for the passage of ectopicendometrium and infectious/inamma-tory agents19-22 (Video 1). The importanceof the role of the fallopian tube in ovariancancer is further evident in studies thatdemonstrate lower rates of ovarian cancerin women who have had their fallopiantubes disrupted by tubal ligation.23-25

These observations prompted ourgynecologic tumor group in BritishColumbia (BC) to initiate a province-wide ovarian cancer prevention initia-tive. We hypothesized that removal ofthe fallopian tubes (bilateral salpingec-tomy [BS]), even in the general popula-tion of women who are at baseline riskfor the development of ovarian cancer,would reduce the incidence of ovariancancer and change the histologic distri-bution of epithelial ovarian cancer inyears to come. Further, we believed thatthis procedure was well within the sur-gical repertoire of gynecologic surgeonsand that access to the fallopian tubes wasfeasible during other routine gyneco-logic procedures such as hysterectomy orsterilization. Finally, experience with BSover the past 5-10 years gave us con-dence that the surgical removal of thetubes would not result in the negativeconsequences of oophorectomy.26-28 InSeptember 2010, we sent an informationaland instructional DVD (Videos 1-5) thatwas directed at all obstetricians and gy-necologic surgeons in BC and that out-lined the role of the fallopian tube inovarian cancer and explained the asso-ciation of high-grade serous cancer withinherited BRCA1/2mutations. We made3 recommendations: (1) considerationof surgical removal of the fallopian tubes

at the time of hysterectomy, even when

471.e2 American Journal of Obstetrics& Gynecolovaries were being preserved, (2) con-sideration of excisional BS for perma-nent sterilization in place of tuballigation, and (3) referral of all patientswith high-grade serous cancer for he-reditary cancer counselling and genetictesting for BRCA1/2 mutations. The rst2 interventions were aimed at womenwho were in the general population whoare at low risk for the development ofovarian cancer (ie, risk of approximately1.5-2% over her lifetime). The thirdrecommendation strived to identifywomen who were at high risk for thedevelopment of ovarian cancer (ie, risk ofup to 50% over her lifetime), becauseidentication of the incident case with aBRCA1/2 mutation in a family enablesother family members to be tested andrisk-reducing strategies (chemical, surgi-cal) to be initiated. In combination, theserecommendations were projected toreduce ovarian cancer rates in the prov-ince of BC by 40% over the next 20 years.Herein, we present the provincial

statistics on the uptake of salpingectomyprocedures in low-risk women across theprovince of BC before and after the 2010campaign. We determine the additionaloperating room (OR) time that isrequired, address surgical approach andregional variation, and determinewhether there are operative or perioper-ative complications that might be attrib-uted to the performance of salpingectomyalone or in addition to other procedures.

MATERIALS AND METHODSDatabase and requested parametersThis large retrospective cohort study wasconducted with the use of data from theCanadian Institute of Health InformationDischarge Abstract Database that capturesdemographic, administrative, and clinicalinformation for all hospital discharges(inpatient and day surgeries) in Canada.Previous studies that validated theDischarge Abstract Database have re-ported a high degree of accuracy in theprocedure codes and primary diagnosiscodes.29 Ethics approval was obtainedfrom the University of British ColumbiaClinical Research Ethics Board. All womenwho underwent any or any combinationof salpingectomy, hysterectomy, oopho-

rectomy,mbriectomy, or tubal ligation in

ogy MAY 2014the Canadian province of BC from Jan. 1,2008 (before campaign initiation), to Dec.31, 2011 (after the campaign and mostrecent complete calendar year data thatwere available at the time of our request),were included in this study. Patients whowere

Regional variationThere are 16 Health Service DeliveryAreas (HSDAs) in BC that are based ongeography and population distribution.We were interested to see whether theeducational campaign had inuenced allregions equally or whether there mightbe isolated areas where knowledgetranslation had failed. We investigatedthe regional variation in the rates ofhysterectomy alone or in combinationwith BS or BSO and the rates of isolatedsalpingectomy across HSDAs as wellas regional differences in surgicalapproach for these procedures.

RESULTSProcedural uptakeThere were 43,973 women who under-went 1 of our requested surgical pro-

because they were not coded as female,and 38 were dropped because they were

study years (P < .001). In contrast, thecorresponding numbers of prophylacticBSOs over the study period did notchange at 64, 54, 64, and 72 over the 4years (P.320). The breakdown of theseprocedures by patient age is illustrated inTable 1 and Figure 3. The number ofwomen who had a hysterectomy with BSincreased in all age groups, particularlyin women who were

performedbydifferent surgical approachesacross the study years. The proportion ofhysterectomies with BS that were per-formed by open procedure decreasedsignicantly from 77% in 2008 to 44% in2011 (P < .001; Figure 4, A). For isolatedsalpingectomies, although the total num-ber of these procedures increased dramat-

signicant difference in surgical approachacross time (P .127; Figure 4, B).

Table 3 shows the differences in pa-tient age, OR time, LOS and read-mission, blood transfusion rates, andaORs for hysterectomies with BS, andisolated salpingectomies by surgicalapproach. OR time was signicantly

y

40-44 677 542 378 188

45-49 700 595 358 143

50-54 275 228 159 97

55 615 623 467 414Hysterectomy with bilateral salpingectomy 267 378 1241 1785

15-39 96 116 307 494

40-44 79 108 355 479

45-49 67 114 392 515

50-54 18 29 113 187

55 7 11 74 110Hysterectomy with bilateral salpingo-oophorectomy 2147 2197 2341 2119

15-39 173 193 208 176

40-44 232 239 229 156

45-49 435 437 455 363

50-54 422 375 447 389

55 885 953 1002 1035Isolated salpingectomy 124 154 734 1492

15-39 60 68 435 934

40-44 17 34 161 350

45-49 31 33 87 132

50-54 6 10 37 49

55 10 9 14 27Fimbriectomy 238 246 296 288

15-39 167 168 196 201

40-44 37 29 53 33

45-49 19 20 22 34

50-54 5 15 13 10

55 10 14 12 10McAlpine. Uptake and risks of opportunistic salpingectomy. Am J Obstet Gynecol 2014.

www.AJOG.org Oncology ResearchMean OR time for sterilization by BSwas longer by 10.2 minutes than tuballigation (mean, 61.0 vs 71.2minutes; P