Leah Jutzi MD, on behalf of OvCaRe

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1 British Columbia s Ovarian Cancer Prevention Initiative Leah Jutzi MD, on behalf of OvCaRe

2 Ovarian Cancer Control Prevention Screening Treatment

3 Treatment Remains a Challenge

4 Screening Does Not Improve Survival SCREENING Japan US (PLCO) UK (UKCTOCS) Starting year # women 183,000 78, ,000 Follow-up (years) /12+ Age Cancers/ 10, MMS 5.8 US Surgery:cancer -- 20:1 3:1 MMS 19:1 U/S

5 Ovarian cancer control Prevention Screening Treatment

6 Is there a precursor lesion? Cervix, colon and breast cancers have precursor lesions What about ovarian cancer? 10 years ago no precursor lesion was known

7 The Lesson from BRCA Tubes and ovaries from prophylactic surgeries When pathologists looked closely Precursor lesions identified Also identified in non-brca mutation carriers

8 Tubal Intraepithelial Carcinoma (TIC) TP53 Ki67 TIC HGSC Köbel et al. Expert Rev Mol Med Aug 1;10:e22

9 Role of the Fallopian Tube in Ovarian Cancer Fallopian tube as conduit Fallopian tube as source Tubal ligation (or salpingectomy) blocks passageway Salpingectomy removes at-risk tissue Potential to develop endometrioid/clear cell carcinomas* Retrograde menstruation (inflammation, endometriosis) Ovulation (tubal inflammation) Development of high-grade serous carcinomas

10 Ovarian Cancer Risk and Tubal Ligation Seih, Salvador, et al. Int J Epidemiology

11 An Opportunity for Prevention 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

12 OvCaRe Education Initiative 2010 Recommended Changes in Practice 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

13 Program Objectives Is this safe? Primary objective Will it work? Will require prolonged follow up

14 Major Perceived Barriers Perioperative Uptake OR Time Length of Stay Ovarian Function (AMH) Readmission Costs & Complications Pain Equipment Regret Blood Loss Short term Long term Patient Age Group Associated Surgical Procedure Efficacy of Campaign Ovarian Cancer Statistics Regional Differences

15 Percentage Change in Key Surgical Procedures in BC Hysterectomy ( ) Share of Hysterectomies With and Without Salpingectomy Over Time 100% Hysterectomy Without Salpingectomy Share of hysterectomies with and without salpingectomy Hysterectomy With Salpingectomy 90% 80% 70% 60% 50% 40% 30% 20% 55% 45% ** 50% 50% 33% 67% 21% 79% Total hysterectomies from remained the same at ~ /year, however the proportion of hysterectomies performed with bilateral salpingectomy hysterectomy w ithout salpingectomy increased by 34% hysterectomy w ith salpingectomy 10% 0% Year

16 Percentage Change in Key Surgical Procedures in BC Sterilization ( ) Share of Sterilization (main diagnosis code) that were done by Salpingectomy vs. Tubal Ligation 100% 90% 80% Tubal Ligation Salpingectomy 70% 60% 99.5% 99.5% 87.9% 66.6% 50% 40% 30% 20% 10% 0% (N=10) (N=9) 33.3% 12.1% Year

17 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

18 The Future Still many missed opportunities?other surgical procedures Unanswered questions Long term effects Overall impact on survival

19 Acknowledgments 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 Centre for Translational and Applied Genomics David G Huntsman Alicia A Tone (now UHN) Nirit Rozenberg Michelle Woo Pathology and Lab Sciences C Blake Gilks Statistical Support Gillian Hanley