As a surgeon treating patients with advanced ovarian cancer, my job has more than its fair share of bleak moments.
This invidious disease is notoriously difficult to diagnose; you can’t screen for it, there are often no early symptoms – and by the time there are (such as bloating or abdominal pain), the cancer is usually advanced.
Little wonder that ovarian cancer is also known as the ‘silent killer’.
When a patient is finally diagnosed (there are around 7,500 new cases in the UK every year and around 4,100 ovarian cancer deaths), surgeons like myself battle against unforgiving odds.
Not least an average five-year survival of less than 50 per cent – less than breast or lung cancers – because it is often caught so late.
Only around 20 per cent of ovarian cancer cases in the UK are caught early.
That’s why we need to look at ways to prevent the disease rather than play a desperate game of catch-up once diagnosis is confirmed.
We need to look at ways to prevent the disease rather than play a desperate game of catch-up once diagnosis is confirmed, writes Professor Michael Worley
We already do this with pre-emptive surgery (to remove at-risk tissue) for those women with a family history of breast or ovarian cancers, usually after a defective gene linked to a high chance of developing these diseases has been discovered.
But I firmly believe we can also help the many thousands more who don’t have this genetic risk – by carrying out surgery to remove the fallopian tubes in women already earmarked for other pelvic or abdominal operations, including hysterectomy, fibroid removal, a Caesarean section or even gallbladder removal.
Known as an opportunistic salpingectomy, it’s usually performed as a form of permanent birth control, as well as to treat conditions such as an ectopic pregnancy or endometriosis.
Yet few people realise it could also protect many more women against ovarian cancer – providing they are certain they don’t want any more children (the procedure leads to sterility).
In fact, the evidence suggests removing the fallopian tubes reduces a woman’s lifetime risk of ovarian cancer to as close to zero as is possible.
But how does removing the fallopian tubes ward off cancer of the ovaries?
The term ovarian cancer is actually misleading since the disease predominantly starts in the fallopian tubes before spreading to the ovaries.
In fact, only a small percentage of – mostly rare – ovarian cancers actually start in an ovary.
This is significant because, unlike taking out the ovaries (which can result in surgical menopause and may increase the risk of cardiovascular disease and osteoporosis), fallopian tube removal is risk-free; they have no other role than the transport of the egg.
Removing them doesn’t cause an early menopause because the ovaries (which dictate menopausal status through hormone production) are left intact.
Ovulation therefore continues normally but the eggs released simply dissolve away.
And there’s no extra risk of bleeding since the fallopian tubes aren’t in a densely vascular area (there’s a limited blood supply).
On top of this, the procedure is swift and simple, taking no more than a few minutes to remove these 4-5cm tubes.
That’s why the operation – for the right women – could be such a game-changer in our battle against this ovarian cancer.
And that’s why I’m part of an initiative involving five top cancer centres in the U.S. — including the Dana-Farber Cancer Institute, where I work — to make more women and doctors aware of the procedure.
We want doctors in the UK and worldwide to follow suit.
Some countries are already on board. Ovarian cancer risk in Canada dropped after salpingectomy was recommended back in 2010 for women undergoing a hysterectomy.
Yet globally most patients – and many doctors – still have no idea that ovarian cancer starts in the fallopian tube and that opportunistic salpingectomy has the potential to slash the risk.
Pushing ahead with this protocol will involve educating general surgeons on the technicalities of fallopian tube removal.
In an ideal world, it would be offered to all women undergoing pelvic or abdominal surgery who are not planning to have any more children. The average age of ovarian cancer diagnosis is 63, but we think cancers in the fallopian tube take several years to develop – so the earlier this procedure can be done the better.
Is it using a sledgehammer to crack a nut? Absolutely not.
We have been trying to find early diagnostics and screening for this disease for decades; nothing works and no screening mechanism (imaging, blood tests, etc) is even close to being useful.
Rather than continue the decades-old fruitless exploration of early detection, we propose a new strategy: prevention.
I’ve treated thousands of women whose prognosis has been dismal and who have wondered why modern medicine couldn’t fix them.
Of the patients who do go into remission following extensive surgery and aggressive chemotherapy, around 70 to 80 per cent will have a recurrence.
Even after treatment, microscopic bits of cancer can remain in the blood or abdominal cavity as the original disease can be distributed over a large area.
And once the cancer returns, it’s almost always terminal.
Every conversation is heartbreaking. So with no early symptoms of this terrible disease, this relatively simple procedure is the most powerful tool we have.
Professor Michael Worley is the director of ovarian cancer surgery at Brigham and Women’s Hospital and Dana-Farber Cancer Institute in Boston, US.
As told to ANGELA EPSTEIN
