Fallopian tube tumorigenesis and clinical implications for ovarian cancer risk-reduction

Ovarian cancer remains the leading cause of gynecologic cancer death among American women. Prevention is the only proven approach to reduce the incidence of the disease. Oral contraception, tubal ligation, and risk-reducing salpingo-oophorectomy (rrBSO) for high-risk groups are all established risk reduction strategies. This paradigm is changing as recent biologic studies suggest that many ovarian cancers, especially high-grade serous ovarian cancers, originate in the distal end of the fallopian tube rather than the ovarian surface epithelium. A putative precursor lesion has been identified called the serous tubal intraepithelial carcinoma (STIC). Theoretically, removal of the fallopian tubes alone may prevent these lesions and prevent overt disease. Opportunistic salpingectomy during benign gynecologic surgery appears to be safe and may offer some protection from ovarian cancer without compromising ovarian endocrine function. Despite a lack of evidence for efficacy, several professional societies now recommend this approach for average-risk women. Whether salpingectomy can also serve as a temporizing measure to delay risk-reducing oophorectomy in women with a genetic predisposition to ovarian cancer remains to be seen. Several ongoing non-randomized clinical trials will test the feasibility of this approach. Therefore, the societal impact of increasing salpingectomy rates on ovarian cancer incidence will be an area of intense focus for the next 10-20 years.