Primary prevention of ovarian cancer: a patient decision aid for opportunistic salpingectomy

Evaluation of a patient decision aid for opportunistic salpingectomy and salpingectomy as sterilization method to prevent ovarian cancer

INTRODUCTION

A patient decision aid on opportunistic salpingectomy and salpingectomy as a sterilization method has been developed to provide uniform counseling and reduce practice variation. The aim of this study was to evaluate the use of the patient decision aid in daily clinical practice to ensure its effectiveness and usability, as well as its influence on the decision-making process and the decision of opportunistic salpingectomy.

MATERIAL AND METHODS

As part of the STOPOVCA-implementation study, we conducted a multicenter observational study in 16 hospitals between July 2020 and February 2024. Patients who were eligible for opportunistic salpingectomy were invited to use the decision aid while they considered whether or not to undergo opportunistic salpingectomy. Digital questionnaires were used to evaluate the decision aid, the decision process, and patients' decisions 6-8 weeks post-surgery.

RESULTS

425 out of 542 patients participated in the questionnaire. A majority of these 425 patients received (N = 357; 84%) and used the decision aid (N = 347; 82%). Two thirds (N = 234; 67%) of those who used the decision aid stated that it increased their knowledge of opportunistic salpingectomy. Patients considered the decision aid a usable aid, allocating a score of 8.1 out of 10 and would recommend it to other patients facing the decision regarding opportunistic salpingectomy. Patients considered the extent to which they were involved in the decision-making process as high, and the decisional conflict low. The majority of patients who used the decision aid opted for opportunistic salpingectomy (N = 326; 95%). Main reasons for choosing opportunistic salpingectomy were the risk-reducing effect of ovarian cancer (N = 311; 90%) and the lack of functionality of the fallopian tubes after childbearing (N = 320; 92%).

CONCLUSIONS

The patient decision aid was used by a majority of patients who received it. The decision aid was regarded by patients as user-friendly, and it was recommended to be used in the decision-making process for opportunistic salpingectomy. Patients stated that the decision aid provides reliable information and increases patients' knowledge of opportunistic salpingectomy.

Peer influence on physicians in adopting opportunistic salpingectomy at the time of hysterectomy

BACKGROUND

Since professional societies recommended counseling patients about opportunistic salpingectomy for ovarian cancer risk reduction, use of opportunistic salpingectomy has increased overall. However, physicians varied in their adoption of this new cancer prevention strategy.

OBJECTIVE

To examine peer influence among physicians as a possible factor affecting their adoption of opportunistic salpingectomy at the time of hysterectomy.

STUDY DESIGN

Using insurance claims data from the Blue Cross Blue Shield Axis database across the United States, we identified female patients aged 18 to 49 who underwent an inpatient hysterectomy in 2019 to 2022. The outcome of interest was opportunistic salpingectomy, defined as complete removal of both (or the remaining) fallopian tubes without concurrent removal of the ovaries. We identified peer relationships among physicians based on whether 2 physicians billed for at least 2 of the same patients among insurance claims in 2017 to 2018. Then for each index physician performing inpatient hysterectomy in the 2019 to 2022 sample, we measured the rate of opportunistic salpingectomy among inpatient hysterectomies performed by all of their peer physicians in 2017 to 2018 (baseline). A multivariable regression analysis was used to examine whether an index physician's baseline exposure to peer physicians' opportunistic salpingectomy rate was associated with the subsequent use of opportunistic salpingectomy among their own patients in 2019 to 2022.

RESULTS

Among 3373 patients who underwent inpatient hysterectomy in 2019 to 2022 (operated on by 1528 index physicians), 1871 (55.5%) received opportunistic salpingectomy. The rate of opportunistic salpingectomy was higher among patients whose index physician had exposure to peer physicians with the highest or second highest quartile of baseline opportunistic salpingectomy rate (64.5% and 59.6%, respectively), compared to those with peer physicians in the lowest quartile of baseline opportunistic salpingectomy rate (44.0%) (P<.001). After adjusting for surgical indication, surgical route, and other patient/physician characteristics, having peer physicians in the highest and second highest quartile of baseline opportunistic salpingectomy rate was associated with a 1.99 (95% confidence interval, 1.46-2.71) times and 1.64 (95% confidence interval, 1.21-2.22) times higher odds of receiving opportunistic salpingectomy, respectively.

CONCLUSION

Sharing patients with other physicians who had high utilization of opportunistic salpingectomy was associated with an increased likelihood of an index physician subsequently using opportunistic salpingectomy at the time of hysterectomy. Future efforts to promote opportunistic salpingectomy use may explore the potential benefit of strategies leveraging physician peer influence.

Ovarian cancer prevention through opportunistic salpingectomy during abdominal surgeries: A cost-effectiveness modeling study

BACKGROUND

There is indication that the fallopian tubes might be involved in ovarian cancer pathogenesis and their removal reduces cancer risk. Hence, bilateral salpingectomy during hysterectomy or sterilization, so called opportunistic salpingectomy (OS), is gaining wide acceptance as a preventive strategy. Recently, it was discussed whether implementation of OS at other gynecologic surgery, e.g., cesarean section, endometriosis excision or myomectomy and even at non-gynecologic abdominal surgery such as cholecystectomy or appendectomy for women with completed family could be feasible. This modeling analysis evaluated the clinical and economic potential of OS at gynecologic and abdominal surgeries.

METHODS AND FINDINGS

A state transition model representing all relevant health states (healthy, healthy with hysterectomy or tubal ligation, healthy with other gynecologic or non-gynecologic abdominal surgery, healthy with hysterectomy and salpingectomy, healthy with salpingectomy, healthy with hysterectomy and salpingo-oophorectomy, ovarian cancer and death) was developed and informed with transition probabilities based on inpatient case numbers in Germany (2019). Outcomes for women aged 20-85 years were simulated over annual cycles with 1,200,000 million individuals. We compared four strategies: (I) OS at any suitable abdominal surgery, (II) OS only at any suitable gynecologic surgery, (III) OS only at hysterectomy or sterilization, and (IV) no implementation of OS. Primary outcome measures were prevented ovarian cancer cases and deaths as well as the incremental cost-effectiveness ratio (ICER). Volume of eligible interventions in strategy I was 3.5 times greater than in strategy III (286,736 versus 82,319). With strategy IV as reference, ovarian cancer cases were reduced by 15.34% in strategy I, 9.78% in II, and 5.48% in III. Setting costs for OS to €216.19 (calculated from average OS duration and operating room minute costs), implementation of OS would lead to healthcare cost savings as indicated by an ICER of €-8,685.50 per quality-adjusted life year (QALY) gained for strategy I, €-8,270.55/QALY for II, and €-4,511.86/QALY for III. Sensitivity analyses demonstrated stable results over a wide range of input parameters with strategy I being the superior approach in the majority of simulations. However, the extent of cancer risk reduction after OS appeared as the critical factor for effectiveness. Preventable ovarian cancer cases dropped to 4.07% (I versus IV), 1.90% (II versus IV), and 0.37% (III versus IV) if risk reduction would be <27% (hazard ratio [HR] > 0.73). ICER of strategies I and II was lower than the 2× gross domestic product per capita (GDP/C) (€94,366/QALY, Germany 2022) within the range of all tested parameters, but strategy III exceeded this threshold in case-risk reduction was <35% (HR > 0.65). The study is limited to data from the inpatient sector and direct medical costs.

CONCLUSIONS

Based on our model, interdisciplinary implementation of OS in any suitable abdominal surgeries could contribute to prevention of ovarian cancer and reduction of healthcare costs. The broader implementation approach demonstrated substantially better clinical and economic effectiveness and higher robustness with parameter variation. Based on a lifetime cost saving of €20.89 per capita if OS was performed at any suitable abdominal surgery, the estimated total healthcare cost savings in Germany could be more than €10 million annually.

Racial Disparities in Sterilization Procedure Performed at Time of Cesarean Section

OBJECTIVES

While bilateral tubal ligation has historically been performed for sterilization at cesarean delivery (CD), recent data supports the use and safety of opportunistic bilateral salpingectomy during CD to decrease lifetime ovarian cancer risk. Prior studies have described racial disparities in sterilization rates, but there is a paucity of data regarding racial disparities in type of sterilization procedure. Our objective was to determine differences in sterilization procedure type performed at CD by race (Black vs. non-Black) to evaluate for equity in bilateral salpingectomy utilization.

STUDY DESIGN

We performed a retrospective cohort study of patients included in the American College of Surgeons National Surgical Quality Improvement Program database who underwent sterilization at time of CD from January 2019, to December 2020, identified using Current Procedural Terminology codes. Patients without documented race were excluded. Multivariable logistic regression was used to determine odds of undergoing bilateral salpingectomy compared with bilateral tubal ligation by race while controlling for confounders.

RESULTS

Of 28,147 patients who underwent CD, 3,087 underwent concurrent sterilization procedure, and 2,161 met inclusion criteria (Black: n = 279; non-Black: n = 1,882). Black patients were significantly more likely to have hypertension (10.8 vs. 5.3%, p < 0.01), bleeding disorders (3.9 vs. 1.3%, p < 0.01), preoperative anemia (hemoglobin < 11 g/dL; 36.9 vs. 21.3%, p < 0.01), and be of American Society of Anesthesiologist class 3 or higher (29.4 vs. 22.5%, p = 0.01) than non-Black patients. After adjusting for differences, Black patients were almost 50% less likely than non-Black patients to undergo bilateral salpingectomy compared with bilateral tubal ligation for sterilization at CD (adjusted odds ratio = 0.52, 95% confidence interval: 0.36-0.75).

CONCLUSION

Despite evidence that bilateral salpingectomy decreases ovarian cancer risk and is safe at CD, there is a racial disparity in bilateral salpingectomy utilization. While the cause of this disparity is unclear, further research is warranted to determine root causes and equitable solutions.

KEY POINTS

· Opportunistic salpingectomy is recommended for primary prevention of ovarian cancer in patients undergoing pelvic surgery who have completed childbearing.. · Black patients were almost 50% less likely to undergo bilateral salpingectomy compared with bilateral tubal ligation than non-Black patients even after controlling for possible confounders.. · Further research is needed to determine root cause of the racial disparity in bilateral salpingectomy utilization rate..

Ovarian Cancer: From Precursor Lesion Identification to Population-Based Prevention Programs

Epithelial ovarian cancer (EOC) is a heterogeneous group of malignancies, including high-grade serous ovarian cancer (HGSC). HGSC is often diagnosed at advanced stages and is linked to TP53 variants. While BRCA variants elevate risk, most HGSC cases occur in individuals without known genetic variants, necessitating prevention strategies for people without known high-risk genetic variants. Effective prevention programs are also needed due to the lack of traditional screening options. An emerging primary prevention strategy is opportunistic salpingectomy, which involves removing fallopian tubes during another planned pelvic surgery. Opportunistic salpingectomy offers a safe and cost-effective preventative option that is gaining global adoption. With the publication of the first cohort study of patients who underwent salpingectomy, specifically for cancer prevention, attention has turned to broadening opportunities for salpingectomy in addition to more targeted approaches. Prevention opportunities are promising with increasing adoption of salpingectomy and the increased understanding of the etiology of the distinct histotypes of ovarian cancer. Yet, further research on targeted risk-reducing salpingectomy with thoughtful consideration of equity is necessary to reduce death and suffering from ovarian cancer.

The nature and impact of patient and public involvement in cancer prevention, screening and early detection research: A systematic review

Patient and public involvement can produce high-quality, relevant research that better addresses the needs of patients and their families. This systematic review investigated the nature and impact of patient and public involvement in cancer prevention, screening and early detection research. Two patient representatives were involved as members of the review team. Databases (Medline, EMBASE, Emcare, Involve Evidence Library) were searched for English-language studies published 1995-March 2022. Titles/abstracts were screened by two reviewers independently. For eligible studies, data were extracted on study characteristics, patient and public involvement (who, when, how, and impact on research outcomes), and reporting quality using the Guidance for Reporting Involvement of Patients and the Public 2-Short Form. Of 4095 articles screened, 58 were eligible. Most research was from the United States (81%) and examined cancer screening or prevention (82%). Community members/organisations/public were the most involved (71%); fewer studies involved patients and/or carers (14%). Over half reported a high-level of involvement (i.e. partner and/or expert involvement), although this declined in later stages of the research cycle, e.g. data analysis. Common positive impacts included improved study design, research methods and recruitment, although most papers (62%) did not describe methods to determine impact. Reporting quality was sub-optimal, largely due to failure to consider challenges. This review found that high-level involvement of patients and the public in cancer prevention, screening and early detection research is feasible and has several advantages. However, improvements are needed to encourage involvement across the research cycle, and in evaluating and reporting its impact.

First step in implementation of opportunistic salpingectomy for prevention of ovarian cancer: Current care and its determinants

INTRODUCTION

Opportunistic salpingectomy (OS) refers to additional removal of the fallopian tubes during abdominal surgery performed for another medical indication, as prevention for ovarian cancer. As OS has been inconsistently implemented, its clinical practice varies worldwide. To reduce this variation, insight is required into current clinical practice and its determinants. Therefore, the study aim was to determine the implementation of counseling and performance of OS between 2015 and 2018, and its patient, surgical, physician, and hospital characteristics.

MATERIAL AND METHODS

Retrospective study using electronic medical records from six different Dutch hospitals: two academic, two large teaching, and two non-teaching hospitals. Patients were considered eligible for OS if they underwent elective non-obstetric abdominal surgery for a gynecological indication from January 2015 through December 2018. Primary outcomes were uptake of counseling and performance of OS. Multilevel multivariable logistic regression analyses were conducted to identify characteristics associated with OS.

RESULTS

A total of 3214 patients underwent elective non-obstetric abdominal surgery for a gynecological indication and were eligible for OS. Counseling on OS increased significantly from 2.9% in 2015 to 29.4% in 2018. In this period, 440 patients were counseled on OS, of which 95.9% chose OS. Performance of OS increased significantly from 6.9% in 2015 to 44.5% in 2018. Counseling for and performance of OS were more likely in patients who had surgery by laparoscopic approach, were counseled by a gynecological resident, or had more than three contact moments before surgery. Additionally, OS was less likely in patients who had vaginal surgery.

CONCLUSIONS

Although the uptake of OS increased from 2015 to 2018, the majority of patients who were eligible for OS were not counseled and did not undergo OS. Its clinical practice varies on patient, surgery, and physician characteristics. Therefore, an implementation strategy tailored to associated determinants is recommended.