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To prevent cancer, more women should consider removing fallopian tubes, experts say

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Monica Monfre Scantlebury, who discovered she had the BRCA1 genetic mutation in 2017, in St. Paul, Minnesota on Jan. 27, 2022. (Jenn Ackerman/The New York Times)

To prevent cancer

Monica Monfre Scantlebury, who discovered she had the BRCA1 genetic mutation in 2017, in St. Paul, Minnesota on Jan. 27, 2022. (Jenn Ackerman/The New York Times)

There is no reliable screening test for ovarian cancer, so doctors are urging women at high genetic risk to have their ovaries and fallopian tubes removed once they have finished having children, usually around the age of 40.

On Wednesday, a leading research and advocacy organization expanded on that recommendation in a way that might surprise many women.

Based on evidence that most of these cancers originate in the fallopian tubes, not the ovaries, the Ovarian Cancer Research Alliance is urging even women who don’t have mutations – which is most women – to have their fallopian tubes surgically removed if they are finished having children and are considering gynecological surgery anyway.

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In such a procedure, surgeons remove the tubes, which lead from the ovaries to the uterus, but leave the ovaries intact. The ovaries produce beneficial hormones even later in life, reducing the risk of heart disease, osteoporosis, and sexual dysfunction. Organ sparing has been linked to lower overall mortality.

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“Ovarian cancer is a relatively rare disease, and typically we don’t send a message to the general population,” said Audra Moran, president, and CEO of OCRA. “We want everyone with ovaries to know their level of risk and the steps they can take to help prevent ovarian cancer.”

To that end, the group has also started offering free home testing kits to eligible women who want to know if they carry genetic mutations such as BRCA1 and BRCA2, which confer a high risk of developing both breast cancer. ovary and breast.

Young carriers of the mutations might consider removing only the fallopian tubes as an interim step to protect against ovarian cancer and to avoid abrupt early menopause, Moran said, although the standard treatment for carriers is also to remove the ovaries.

While women who carry the BRCA1 and BRCA2 mutations have a very high risk of ovarian cancer, the majority of women with the disease do not carry the mutations.

The new advice is an acknowledgment that efforts to develop lifesaving screening tests for the early detection of ovarian cancer have failed and that women should consider more proactive measures.

A large clinical trial in Britain found that imaging scans and blood tests for early detection of ovarian cancer were not detecting cancer early enough to save lives.

Women have been told to heed vague symptoms, such as bloating, which could indicate something is wrong, but experts say there is no evidence that vigilance prevents deaths because the symptoms occur usually later in the course of the disease.

The Society of Gynecologic Oncology, an organization of doctors who treat gynecological cancers, has endorsed the new push to make genetic testing more accessible and promote prophylactic removal of the fallopian tubes in women without genetic risks.

“It’s considered experimental,” said company president Dr. Stephanie Blank. But “it makes scientific sense and has a lot of appeals.”

“Removing the tubes isn’t as good as removing the tubes and ovaries, but it’s better than screening, which doesn’t work,” she said.

Dr. Bill Dahut, Scientific Director of the American Cancer Society, said: “There’s a lot of good data behind what they’re suggesting, showing that for people who have had this surgery, cancer incidence rates of the ovary are less.

“If you look at biology, maybe we should call it fallopian tube cancer and think of it differently because that’s where it all starts,” he said.

Ovarian cancer ranks fifth among cancer deaths in women, according to the American Cancer Society, and accounts for more deaths than any other cancer of the female reproductive system. Each year, some 19,710 women in the United States are diagnosed with ovarian cancer and approximately 13,000 women die from it.

The disease is a particularly stealthy malignancy and is therefore often diagnosed at a very advanced stage. Ovarian cancer is much less common than breast cancer, which is diagnosed in 264,000 women and 2,400 men each year in the United States, but its survival rates are much lower.

In women with BRCA1 and BRCA2 gene mutations, surgeons usually remove the ovaries along with the fallopian tubes – between ages 35 and 40 in women with the BRCA1 mutation and between ages 40 and 45 in women with the mutation BRCA2, Blank said. Ideally, women will have finished childbearing by then.

But women who don’t have a clear family history of ovarian or breast cancer may not know they carry the mutations.

Monica Monfre Scantlebury, 45, of St. Paul, Minnesota, discovered she had the BRCA1 mutation in 2017 when her younger sister was diagnosed with metastatic breast cancer at age 27.

Their mother didn’t have the mutation, meaning they inherited it from their deceased father. His mother, Scantlebury’s grandmother, had died in her forties of breast and ovarian cancer.

While heart disease was discussed in the family, women’s cancers were only whispered about, she recalled in an interview. After her sister died in 2020, Scantlebury had her tubes removed, along with an ovary that appeared to contain growth.

“I was in my early 40s and my doctors were less concerned about me getting breast cancer then and more concerned about my high risk of ovarian cancer,” he said. she declared.

A few days later, she received a call from doctors saying cells suspected to be precursors to high-grade serous ovarian cancer had been found in one of her removed fallopian tubes. Scantlebury decided to have her uterus and cervix removed, along with the remaining right ovary.

These decisions were not easy. “I made the choice not to have biological children, which was difficult,” she said. “And I’m still at risk for breast cancer.” But, she added, “I carry the name of my grandmother and I believe that the operation prevented me from having the same obituary as her.”

The practice of removing the fallopian tubes while a patient is already undergoing another pelvic surgery, called an opportunistic salpingectomy, is already part of standard care in British Columbia, said Dr. Dianne Miller, who until recently directed the gynecological oncology services there.

“Fifteen years ago it became clear that the most deadly and common types of high-grade cancers actually originated in the fallopian tube rather than the ovary and then spread very rapidly,” Miller said.

By the time women experience symptoms like bloating or abdominal pain, she says, it’s too late to do anything to save lives.

“I remember when the light bulb goes out when many of these cancers are probably preventable because many women have surgery at some point for a hysterectomy, or fibroid removal, or tubal ligation. “said Miller.

It was once common to remove the ovaries during a hysterectomy, as it reduced the risk of breast cancer and virtually eliminated ovarian cancer. For high-risk women, this is still the preferred option.

But for women at average risk of ovarian cancer, Miller said, removing only the fallopian tubes is a “win-win” situation, reducing the risk of ovarian cancer even if the intact ovaries continue to produce. small amounts of hormones that help keep the brain and heart healthy. later in life.

“As oncologists, our eyes are on curing cancer,” Miller said. “But if there’s one thing that’s absolutely better than curing cancer, it’s not having it in the first place.”

© 2023 The New York Times Company

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