2014 ovarian cancer national conference: british columbia’s ovarian cancer prevention initiative
TRANSCRIPT
British Columbia’s Ovarian Cancer Prevention Initiative
Leah Jutzi MD, on behalf of OvCaRe
Prevention
Screening
Treatment
Ovarian Cancer Control
Treatment Remains a Challenge
http://seer.cancer.gov/statfacts/html/ovary.html
Screening Does Not Improve Survival
SCREENING Japan US (PLCO) UK (UKCTOCS)
Starting year 1985 1993 2001
# women 183,000 78,000 200,000
Follow-up (years) 9.2 13 8/12+
Age 58 55-74 50-74
Cancers/ 10,000 6.5 6.2 6.8 MMS 5.8 US
Surgery:cancer -- 20:1 3:1 MMS 19:1 U/S
Prevention
Screening
Treatment
Ovarian cancer control
• Cervix, colon and breast cancers have precursor lesions
• What about ovarian cancer?
• 10 years ago no precursor lesion was known
Is there a precursor lesion?
Tubes and ovaries from prophylactic surgeries
•When pathologists looked closely…
•Precursor lesions identified
•Also identified in non-BRCA mutation carriers
The Lesson from BRCA
Köbel et al. Expert Rev Mol Med. 2008 Aug 1;10:e22
TIC
HGSC
TP53 Ki67
Tubal Intraepithelial Carcinoma (TIC)
Role of the Fallopian Tube in Ovarian Cancer
Retrograde menstruation (inflammation, endometriosis)
Fallopian tube as source Fallopian tube as conduit
Tubal ligation (or salpingectomy) blocks passageway
Salpingectomy removes at-risk
tissue
Development of high-grade serous
carcinomas
Ovulation (tubal inflammation) Potential to develop
endometrioid/clear cell carcinomas*
Ovarian Cancer Risk and Tubal Ligation
Seih, Salvador, et al. Int J Epidemiology. 2013.
• 30% have a hysterectomy
• 60% have the ovaries and tubes left in place
• 30% have a tubal ligation
• 18% of women in BC with ovarian cancer had a prior hysterectomy with tubes and ovaries left in place
An Opportunity for Prevention
OvCaRe Education Initiative 2010
1. Removal of fallopian tube at hysterectomy
2. Perform salpingectomy in place of tubal ligation
3. Genetic counseling and BRCA mutation screening in all women with high-grade serous carcinoma
Goal: ~40% reduction in ovarian cancer deaths in 20 years
10-20% through salpingectomy at time of hysterectomy
10-20% through salpingectomy instead of tubal ligation
10-20% through risk-reducing surgery in patients with BRCA mutations
Recommended Changes in Practice
Program Objectives
• Is this safe?
– Primary objective
• Will it work?
– Will require prolonged follow up
Major Perceived Barriers
Readmission
Equipment
Blood Loss
Regret
Pain
Ovarian Function (AMH)
OR Time
Length of Stay
Costs &
Complications
Patient Age Group
Ovarian Cancer
Statistics
Regional Differences
Associated Surgical
Procedure
Efficacy of Campaign
Perioperative
Sho
rt – term
Lon
g – term
Uptake
Share of hysterectomies with and without salpingectomy
45%50%
67%
79%
55%50%
33%
21%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2008 2009 2010 2011
hysterectomy w ithout
salpingectomy
hysterectomy w ith
salpingectomyPerc
enta
ge
Year
Share of Hysterectomies With and Without Salpingectomy Over Time
Hysterectomy Without Salpingectomy
Hysterectomy With Salpingectomy
Total hysterectomies from 2008-2011 remained the same at ~5000-5400/year, however the proportion of hysterectomies performed with bilateral salpingectomy increased by 34%
**
Change in Key Surgical Procedures in BC Hysterectomy (2008-2011)
Change in Key Surgical Procedures in BC Sterilization (2008-2011)
Perc
enta
ge
Share of Sterilization (main diagnosis code) that were done by Salpingectomy vs. Tubal Ligation
Tubal Ligation
Salpingectomy
33.3%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2008 2009 2010 2011
87.9% 66.6% 99.5%
12.1%
99.5%
(N=10) (N=9)
Year
Short-Term Outcomes
• No significant increase in
• OR time
• Length of stay
• Readmission to hospital
• Blood transfusion
• No impact on ovarian function
Morelli et al. Gynecologic Oncology. 2013.
The Future
• Still many missed opportunities
• ?Other surgical procedures
• Unanswered questions
• Long term effects
• Overall impact on survival
Acknowledgments Centre for Translational and Applied Genomics David G Huntsman Alicia A Tone (now UHN) Nirit Rozenberg Michelle Woo
UBC & BCCA Gyn Onc/Med onc Jessica McAlpine Gavin Stuart Tom Ehlen Sarah Finlayson Mark Carey Mark Heywood Janice Kwon Marette Lee Shannon Salvador Mona Mazgani Paul Hoskins AnnaTinker Ken Swenerton Susan Ellard Ursula Lee Trevor Cohen Leah Jutzi
Pathology and Lab Sciences C Blake Gilks
Statistical Support Gillian Hanley