Opportunistic Salpingectomy Surgery: A Technical Guide

[Amy Park MD]
Even tubal ligation too, which why-- and we'll get into this later, but the literature that I've seen about performing opportunistic salpingectomy, the crucial part is prioritizing the getting the fimbriae-- why would a tubal ligation, just cutting it in half, help?

[Kara Long Roche MD]
It's interesting that in some of these big studies, it may be that the tubal ligation had a greater impact on the endometriosis associated ovarian cancers. The endometrioid and the clear cell that really, their biological origin is endometriosis coming out of the fallopian tubes, landing on the ovary, and then undergoing carcinogenesis and the tubal ligation. In some of the bigger studies, when they really went back and subtyped, it looked like the tubal ligation had the biggest impact on the endometriosis associated cancers, which then even lends a little more strength to the salpingectomy as a population-based prevention strategy. Because you would decrease not only serous carcinoma by removal of the fimbriae but you will also accomplish that blocking of the endometriosis associated processes.

[Amy Park MD]
When would you pinpoint this sea change? I seem to remember around 2017 or something like that. Is that around the time where we all came around?

[Mark Hoffman MD]
I can actually say I came to Kentucky in 2012 and someone close to me said, "I think I'm going to get my tubes out," and this is a person not in medicine. I'm like, "For what?" They said, "I was reading. My aunt had ovarian cancer and I read somewhere about it.” Again, this is not a doctor. I was like, "Oh, that's ridiculous. I would know that. I'm an OBGYN. I just finished training." I called a couple of friends, GYN oncologists, that I knew from training, and they're like, "Actually we're starting to do that." This person that I knew that had brought it up to me was the first person I knew, and that was in 2012, 2013, to get their tubes out. It was like they were the first person to ask their gynecologist to do this surgery.

It was like, boom, and they actually brought it up. I was at a lecture and an ovarian cancer specialist was talking about it. When I brought it up and they looked at me like, "Who do you think you are?" Ovary cancer and the fallopian tubes. It was somebody who had been studying this disease for decades. I think, the next year there was a big update and they had a couple slides back in their talk, but it came out of nowhere for those of us who were doing it. It just feels like it just happened. Obviously a lot of people put a lot of work into it, but I'm curious, Amy's question: what happened? How did this sea change happen?

[Rebecca Stone MD]
If you think back, SGO published recommendations about it first in 2013 and then ACOG put out their first practice bulletin in 2015. That's probably why, Mark, 2017 would have been about the right time. Usually, once a practice bulletin gets out it usually shows up in our recertification for boards. We read it and then by 2017, people are increasingly familiar with it. It was really around that time, not just in the United States, but several professional level societies globally, really began to endorse salpingectomy as a primary prevention strategy for ovarian cancer.

Canada's been a real leader in this, but England, Germany, certainly Denmark, Sweden and Australia. I think there's still a lot of work to be done. Kara and I, we're spending the back end of our lives working on this. But you're right, it really has been over the past couple years that there's been increasing advocacy for it. Amy, to your point, I think why tubal ligation? The other thing I think about a lot is, why the fimbriated end of the fallopian tube? What is the deal with that? When you think about the fimbriated end of the fallopian tube, it's like a hotbed of missense P53 mutations, the P53 being our canonical tumor suppressor gene.

That part of our body is perhaps one of the most P53 mutated organs that we walk around with on the daily. Why is this? It's because, I think, it's just getting attacked by the ovary. The ovaries are ovulating and exploding on it every month. 14 days later when a woman has her period, there's some retrograde menstruation that ends up in the pouch of Douglas. Then the fimbriated end of the tube just sits in there and marinates in all that blood and gets all this free radical damage. It just accumulates these P53 mutations over time.

Anything that we can do to decrease retrograde menstruation, decrease the number and intensity of menstrual cycles, ovulatory cycles. Whether it be pregnancy or breastfeeding or birth control pills, all of these things decrease a person's lifetime risk of developing ovarian cancer. Maybe, in part, due to that mechanism.

[Mark Hoffman MD]
All of these things. Like Amy said, why would tubal ligation matter? We had all these facts that we knew work like birth control pills. We don't really know why, but now we've got this possible explanation that might tie it all together for a disease that some really hard working, brilliant people have been working on. This disease like you said, for a century or more to have a breakthrough like this. I'm not a gynecologist, but it seems like a pretty mind blowing thing to be working on this stuff as it's happening.

[Kara Long Roche MD]
For a disease where we're really still scratching our heads as to how to detect it early, really, the quest for screening tests is still active. Unfortunately, we're not close to having one. This whole tube hypothesis that ties everything together has completely opened the door for prevention options or risk reducing options. It's really wild to see this come to fruition in our careers.

[Amy Park MD]
Can you tell us, what is opportunistic salpingectomy, when do you do it, how do you perform it, when are the opportunities? We're talking about hysterectomy, but my colleagues doing OB are doing it at the time of C-section. More power to them, those veins are like the size of my finger! Tell us a little bit more about it, because I think you have an important view. Then as a follow up to that, I want to ask, when do you think we're going to see the results?
[Kara Long Roche MD]
I'll start by explaining what it is. The concept is that removal of the fallopian tubes will reduce risk. How do we expand access to that option safely? Becky and I always think about it as, let's start with the safest and the most practical approach, which is when a gynecologist or an obstetrician is already there. The opportunities then, when a gynecologist or obstetrician is already there, that's your foundation of opportunity. Instead of tubal ligation at the time of hysterectomy, certainly C-section in someone who has finished childbearing.

Even if you're taking out an ovarian cyst in someone who's completed childbearing, those are all the lowest hanging fruit for when the tube should come out. Right now, that's the situation where we have the most evidence. There's a really robust body of evidence that supports salpingectomy being a safe, feasible and cost effective option in those situations. I'll throw it over to Becky to talk about all the places that we can expand it and where we don't yet have data, but we're working on it.

[Mark Hoffman MD]
Are we looking closely enough at the tubes? I'm taking out all these tubes. I'm sure you guys, as oncologists, are going to say no, and the pathologists are like, "Yes, it's fine."

[Rebecca Stone MD]
Oh no.

[Kara Long Roche MD]
Hey, how long do you have for an answer?

[Rebecca Stone MD]
I know! I mean I spent an hour on the phone with one of our pathologists on Saturday about this because I basically was like, "I've heard that maybe we look at 1% or less of a fallopian tube histopathologically." We sat there and went through the math, of the huge surface area of the fimbriated end. Many places will just bivalve the tube and look at one section from each side of the tube and the fimbriated end. It's probably honestly looking at only one star in a galaxy is like what fraction of the fallopian tube we're actually looking at.

That's why we have this collaboration with MIT as part of our breakthrough cancer work to innovate diagnostics. In this era of molecular imaging, why can't we take a whole organ out, label it and look at it with special imaging to really target areas where there are abnormalities and focus on those areas as opposed to just randomly sectioning an organ and hoping we find the area of interest?

[Amy Park MD]
That happened to me. I had somebody I did a cervicopexy on, I took out her tubes. A year later she comes back with disseminated ovarian cancer. They looked back at the tubes later and it was there. Then the other thing I will say in terms of best practices is, how about taking out a uterus and then taking out the tubes and then the pathologist calls you and says, "We didn't find the tubes." I was like, "Is this for real, are you punking me? What's going on?"

[Mark Hoffman MD]
It took me one time for that to happen. Like, "Oh we never got tubes." Now I do left tube, right tube.

[Amy Park MD]
That's what I do too.

[Mark Hoffman MD]
We take out the tubes separately from the uterus. We always take out the tubes first in the hysterectomy, then we do the rest every time and we get down all the way to the little blebs.

[Amy Park MD]
I do that too, I agree, Mark. It happened to me twice and I was like never again, because I know what happens. The pathology tech sections the specimen and then they prepare the side and then they didn't catch the little piece that I got and labeled, 'tube'. I also send them in as separate specimens. Because sometimes I'll get the pathology report and I'm like, "This is incorrect and this is like the gospel." Also, I just wanted to circle back, and can you tell people what STEC is?

[Rebecca Stone MD]
Yes, STEC is essentially like stage zero or ENCI 2 cancer. It's the tubal equivalent to CIN 3 for instance, we think. I think we have a lot to learn about STEC. I think there's probably a very wide spectrum of STEC. There's probably some bad-acting STECs and there's maybe some more friendly STECs. As we do really come to understand STEC biology, which is part of this project, the science part of this project. I think we're going to learn a lot more about them.

[Amy Park MD]
What do you think the uptick has been? Do we have data on that?

[Rebecca Stone MD]
If you look at the data, you have to take the data, I think, with a grain of salt because there's a lot of challenge in gathering this data. With the way that we currently do billing and coding in the United States, lots of procedures are bundled, like hysterectomy. We don't have an ICD-10 procedure code, actually, that is specific to opportunistic salpingectomy.

We have one for prophylactic salpingectomy, so removal of the tubes for persons who have risk factors like genetics or family history. Right now, the way that we do coding in the United States and how insurance recognizes that, a risk factor of being a woman or having a fallopian tube is not acknowledged. Our coding, actually, is outdated and it's not consistent with the current standard of care.

[Mark Hoffman MD]
There's no CPT code either. The CPT codes that exist, one is sterilization, so it's a bilateral code. It is with transection. ACOG, for a while, was telling us to do that, but it doesn't have nearly as many RVUs as the adnexal laparoscopic-- adnexal code, which is tube and/or ovary, which is a unilateral code associated with pathology and, I think, the vignettes for endometriosis. You're getting a bilateral-- people are billing, and correctly, because it is removing two fallopian tubes, but my guess is CMS will step in and probably demand that we redo those codes.

There is no laparoscopic bilateral salpingectomy for the purposes of sterilization because most CPT codes have to be associated with a diagnosis code. You can't do a cancer surgery diagnosis for someone who's got a broken finger. That has to match up. We're behind on this. This is something I said on ACOG's committee on Health, Economics, and Coding a decade ago and it was something we were talking about even then, but these things take a lot of time. That's how new this is.

[Amy Park MD]
How do you measure the uptake? You're talking about billing data, but are there estimates, at least?

[Rebecca Stone MD]
That's what I'm saying, if you look at the papers on this, you have to look at it with a grain of salt. I think we're doing a pretty good job of performing salpingectomy at the time of hysterectomy, as gynecologists. I've seen estimates as high as 65% to 85% of hysterectomies, but the current data on performance of salpingectomy in lieu of tubal ligation is not nearly as good for some of the reasons we talked about at the time of C-section, but also even at interval surgical sterilization. Some of the data would suggest that we're only at 18% uptake.

[Kara Long Roche MD]
One of the challenging things, and this is part of the reason why this quest is so complicated, is that there's legal implications, or policy, because the laws, state-based laws federal about surgical sterilization, and what Medicaid and Medicare will cover are very nuanced. There are certain states, for example, that don't include salpingectomy as a reimbursable, acceptable, procedure for sterilization.

[Mark Hoffman MD]
I didn't know that. Wow.

[Kara Long Roche MD]
There are physicians in certain states who may not be able to bill for a salpingectomy, or get reimbursed for a salpingectomy for sterilization. This complicated tangle that needs to be untangled is everything from the law, to some outdated policies surrounding sterilization with Medicaid, to the billing, to the coding, and to the databases. One thing that we're trying to do, and, hopefully, are succeeding in doing, is to put salpingectomy into some of the national databases, like NSQIP database, for example.

If we could just include that variable, we would be able to start the collection. We've had to really think about this from this amazingly comprehensive approach. I think Becky and I have thought about things like billing, and coding, and laws, and policy, way more than we ever thought we would have had to as GYN oncologists.

[Mark Hoffman MD]
As I'm thinking about it, hysterectomy, with or without tubes and/or ovaries, given the hysterectomy codes, won't tell you whether it was done--

[Kara Long Roche MD]
No. Someone would have to go check every path report, and that's not a feasible way.