Christopher P. Crum, MD
About one in every seventy women will get ovarian cancer in their lifetime. And this is in contrast to breast cancer, which is, as you know, much more common. As many as one in nine women now are getting breast cancer.
The conventional way to diagnose the ovarian cancer is usually after a woman comes in with a complaint. She may have abnormal bleeding, but more commonly she may just have some feeling of unease. She has a feeling of bloating or some other type of abdominal symptom. And then the diagnosis would routinely be made by doing some kind of imaging such as an ultrasound or a CT scan, if you will. But often in the end, the diagnosis is made by simply laparotomy or surgery where the tumor is then discovered.
A small percentage of the population is born with a mutation in one of their two BRCA 1 or BRCA 2 genes. Women who are born with these mutations have a much greater risk of developing breast or ovarian cancer in their lifetime and it may be as high as 80 percent for breast cancer for some of these genes, and as high as 40 percent for ovarian cancer.
So in general, if a woman is known to have the mutation, it is recommended that she consider having her ovaries and fallopian tubes removed around age 40 because at age 40 the risk begins to accelerate, that she might develop ovarian cancer. It will reduce the risk of ovarian cancer by about 90 percent.
Other things that can reduce risk, though, may have nothing to do with genes per se, at least as we know it. For example, you can reduce the risk of developing ovarian cancer, a woman can, if she has multiple births or if she gives birth multiple times during her life. For some reason, that reduces the risk. Women on oral contraceptive pills have a reduced risk of ovarian cancer as well as breast cancer. Women who have breast fed apparently have a lower risk. Even tubal ligation, which of course is a sterilization technique, for some reason reduces the risk of developing ovarian cancer. So these are other factors that do influence cancer risk over the lifetime.
We developed a protocol around 2005 for examining the fallopian tubes of women to see if we could identify the origins of ovarian cancer. Well, we came to the conclusion that if some of these tumors might be starting from the fallopian tube, they would more likely start in the distal part of the tube, which is the end of the tube. And this is called the fimbriae. And so in 2005, we developed this protocol called the SEE-FIM protocol. which is very simply paying more attention to the distal part of the tube when we examine the tubes in these women.
We published this work and just about everybody else in the business, in the pathology field, began to use this protocol for evaluating the fallopian tubes in women who had BRCA mutations. And what they discovered, as we all did, is that out of every hundred women who undergo this prophylactic procedure, from five to ten percent will prove to have a very early cancer in the fallopian tube.
We then applied the same technique, or the same protocol to women who came in with symptomatic cancer. And we found what we thought was a credible starting point in maybe 50 percent of those cases.
I would emphasize the tumor we're talking about here is the so-called high grade serous carcinoma. There are other cancers that clearly start in the ovaries, such as endometrioid cancers or certain other types of cancers.
What is the greatest interest now is should we take the entire fallopian tube out of women when we have the opportunity?
So for example, a woman is coming in to have a benign uterine tumor taken out. So they take out her uterus and let’s say she's 45. And at that age, she wants to keep her ovaries. So what they would do in a case like this is consider removing just the fallopian tubes so her uterus and fallopian tubes would be taken. And the reason the fallopian tubes would be taken would be specifically to reduce her risk of developing ovarian cancer.
Retrospective epidemiologic studies of women who've had their fallopian tubes removed by themselves -- in other words they do studies where they find populations where this is done -- have shown about a 50 percent reduction in ovarian cancer risk.
The research that we're particularly interested in as pathologists is to really try to understand where all of these high grade cancers come from. So we continue to do studies to carefully examine the ovaries and the fallopian tubes in women who've got these cancers looking for other sources of tumor origin. And that's a central theme of our work. We're also doing work looking for additional risk factors that might be found in the fallopian tubes. We're also looking for early detection opportunities in the fallopian tube, or even by examining other parts of the GYN tract to see whether or not one can identify risk or risk associated biomarkers.
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