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