New opportunities for opportunistic salpingectomy: Leveraging non-gynecologic surgeries for ovarian cancer prevention

Ovarian cancer remains a highly lethal malignancy due to lack of effective screening and treatment to reliably eradicate the disease. In this issue of Gynecologic Oncology Reports, Cook et al. explore expanding opportunistic salpingectomy for ovarian cancer risk reduction to general surgery (Cook et al., 2025). With the addition of opportunistic salpingectomy (OS) or salpingo-oophorectomy to minimally invasive cholecystectomy, ventral hernia repairs, or bariatric surgery, the authors estimate a 20–28 % reduction in incident ovarian cancer cases. This projection is both striking and provocative, raising important questions about patient selection, multidisciplinary collaboration, and implementation feasibility.

Embracing a prevention mindset

With the recognition that most high-grade serous ovarian cancers likely originate in the distal fallopian tube (Kurman and Shih, 2010), several national and international societies have embraced OS for ovarian cancer prevention (ACOG Committee, 2019, Ntoumanoglou-Schuiki et al., 2018). This has led to increasing adoption of OS at the time of hysterectomy and in lieu of tubal ligation (Karia et al., 2022, Mandelbaum et al., 2020). Cook et al propose broadening the intervention to patients undergoing non-gynecologic laparoscopic or robotic procedures who, by virtue of existing abdominal access, can potentially undergo simultaneous removal of both fallopian tubes or the adnexa when appropriate. Given the large volume of these particular abdominal surgeries and that over 50 % of female patients undergoing them are potentially eligible, the authors estimate that around 500,000 women could benefit annually from OS for ovarian cancer risk-reduction.

At present, OS is rarely performed during non-gynecologic surgery (Cathcart et al., 2023) and uptake in the field of OB-GYN has been relatively slow (Stone et al., 2023). Many obstetrician-gynecologists have yet to fully champion OS, citing concerns about safety, cost at the time of cesarean delivery or postpartum, and the lack of definitive effectiveness data for ovarian cancer risk reduction. Cook et al. modeled a 65 % risk reduction based on the hazard ratio (HR) reported by Falconer et al., which examined bilateral salpingectomy for benign indications among Swedish women operated between 1973 and 2009 (Falconer et al., 2015). However, it is important to note that this HR pertains to salpingectomy performed for the management of benign tubal disease, not specifically for ovarian cancer prevention. The study did not control for key confounding variables, and its findings apply to ovarian cancer overall rather than exclusively to high-grade serous histology.

Two studies are specifically evaluating the impact of salpingectomy on ovarian cancer prevention: one is the ongoing retrospective cohort study of OS at hysterectomy and in lieu of tubal ligation by the OVCARE team in British Columbia, Canada (Hanley et al., 2022), and the other is a registry-based randomized controlled trial for OS at hysterectomy in Sweden (Idahl et al., 2019). However, given the need for ensuring adequate follow-up time for the Canadian OS cohort and for target sample size accrual to the Swedish trial, reliable effectiveness data and the number needed to treat remain unavailable. These data are forthcoming and may inspire more gynecologists to routinely offer OS. However, validating the Swedish and Canadian findings with U.S. data would further strengthen the case for OS adoption. This is certainly easier said than done. At present, most hysterectomies are performed minimally invasively in outpatient settings, and at least 50 % of sterilizations occur at the time of delivery (Karia et al., 2022, Moore et al., 2006). Ambiguous Current Procedural Terminology procedure coding and bundled care in these scenarios make it difficult to use claims data to accurately measure the impact of salpingectomy on ovarian cancer incidence in the U.S.

Deficiencies in medical coding also present a significant barrier to implementing OS during non-gynecologic surgeries. Specifically, no ICD-10 diagnosis code exists for salpingectomy performed for ovarian cancer risk reduction in average-risk women. The current prophylactic salpingectomy code (Z40.03) requires documented familial or genetic risk for reimbursement. As a result, OS is typically submitted for reimbursement linked to the ICD-10 code for the primary procedure. For example, if OS is performed during a hernia repair, it is billed under the hernia repair ICD-10 code, making it appear to payors as though the indication for OS was hernia repair. If OS becomes more widely practiced without proper coding in place, this could lead to erroneous billing and potential payback demands from insurers. Addressing these coding issues is essential for integrating OS into routine surgical practice.

Fortunately, emerging studies evaluating the acceptability, feasibility, and cost-effectiveness of OS at non-gynecologic surgery are very motivating (Kahn et al., 2023). Tomasch and colleagues were the first to demonstrate the acceptability and feasibility of OS at the time of laparoscopic cholecystectomy. OS was accepted by the majority of Austrian women age ≥45 (62 %) and completed in 93 % of cases with minimal additional operative time (approximately 13 min) and without complications (Tomasch et al., 2020). In two abstracts focusing on bariatric surgery, the fallopian tubes could be accessed in 80 % of cases (Sagmeister et al., 2023) and salpingectomy could be completed without additional incisions or instruments (Williams, 2018). Cost-effectiveness analyses utilizing various modeling techniques have consistently shown gains in quality-adjusted life-years and cost-savings through performing OS at the time of abdominal surgeries such as cholecystectomy, appendectomy, hernia repair, colon resection, and gastric bypass (Fisch et al., 2024). These findings align with the cost-effectiveness evaluation in Cook et al.’s analysis, where even modest reductions in ovarian cancer incidence can offset the added operative time and cost.

Patient selection and health equity

One of the unique aspects of Cook et al.’s study was its assessment of acceptability, as data on the acceptability of OS among U.S. women remain limited. In their study, 81 % of 59 survey respondents who received a one-page informational handout expressed high interest in undergoing OS during planned non-gynecologic surgery. The sole reason for declining the intervention was the desire for future childbearing.

Notably, approximately a quarter of survey respondents identified as non-White, and within this subgroup, the acceptance rate was 73 %. While the sample size was small, this finding suggests that OS may be less acceptable among non-White and Hispanic women. Recent claims data indicate that Hispanic and non-White women are actually more likely to receive a tubal ligation than a salpingectomy for permanent contraception (Karia et al., 2022). The reasons for this disparity are unclear, but potential contributing factors—such as provider bias, language barriers, health literacy gaps accounting for misunderstanding about the reversibility of tubal ligation, and exclusionary health policies and payment structures—warrant further investigation. Tackling these issues within OB-GYN practice now could significantly aid the equitable and inclusive integration of OS into general surgery.

Another key consideration in patient selection is age. Cook et al. suggest an age threshold of 60, recommending OS for women under 60 years and salpingo-oophorectomy for those 60 years and older. However, the optimal age threshold for risk reduction remains uncertain. A study from Denmark suggests that the protective benefit of salpingectomy may begin to decline significantly after age 50 (Duus et al., 2023). If confirmed, these findings suggest that OS may be most effective for women 50 years and younger.

Implementation and collaborative models

Four registered clinical trials are underway around the world investigating OS during non-gynecologic surgery. We eagerly await the results of Cook et al’s feasibility study, NCT04176484 (Cook, 2024). A similar trial evaluating feasibility with operative metrics as the primary outcome measure recently completed accrual in Israel (Josephy, 2023). Two additional trials are also actively recruiting. Uptake, safety, and cost-effectiveness of OS in reproductive-aged average-risk patients undergoing open and laparoscopic colorectal surgery is being investigated by the OVCARE team (Hanley, 2024). In the United States, a multicenter trial is underway to assess the acceptability, feasibility and safety of OS in average-risk patients age ≥45 after completion of an educational module (Roche, 2024).

While the potential benefit for ovarian cancer risk reduction is clear, practical issues need to be considered to safeguard patient safety and informed decision making before broad implementation:

(1) Multidisciplinary coordination: Streamlined protocols incorporating gynecologic surgeon input—either via immediate collaboration with joint surgeries or specialized training and credentialing for non-gynecologic surgeons—will be critical in ensuring safe and skillful execution of OS. A mechanism for performance monitoring that can be integrated into routine quality and safety practices is needed to support the initiative. Other considerations, such as optimizing patient positioning for pelvic exposure will also require additional time and resources in the operating room.

(2) Patient counseling and informed consent: The approach taken by Cook and colleagues underscores the critical role of patient education in medical decision-making. They integrated a concise, one-page educational handout into the routine surgical consent process, demonstrating a simple yet effective way to inform patients. However, educational materials should not be limited to a single document—comprehensive patient education should include multiple models, such as counseling sessions, decision aids, and digital resources, to ensure patients fully understand their options, particularly regarding sterilization, menopause, and surgical risks. Further, people should be informed about the option of OS over the course of their lives, rather than encountering it for the first time when facing a primary procedure where OS could be incorporated, so that they can proactively choose OS when the timing is right for them.

(3) Coding mechanism: There is no diagnostic or discrete procedural code in the U.S. for risk-reducing salpingectomy for patients at average-risk for ovarian cancer. When OS is added to either gynecologic or non-gynecologic surgery, appropriate coding is necessary both for reimbursement and for epidemiologic outcomes research.

It is striking that just now we are prioritizing patient education on OS, despite its introduction into OB-GYN practice in 2015. Arguably, these materials should have been developed and distributed to our own patients much earlier. Growing published and unpublished concerns in the Netherlands, Canada, and the U.S. suggest that many women underwent salpingectomy during hysterectomy or in lieu of tubal ligation over the past years without full awareness of the procedure or its rationale (Rodowa et al., 2024). This highlights a broader issue—true informed consent requires more than a signature; it requires understanding.

For educational mobilization to be effective, it must bridge the literacy gap between clinicians and patients. The National Assessment of Adult Literacy provides critical insights into the magnitude of this gap, which varies based on social determinants of health (Kutner et al., 2006). Notably, a third of Medicaid beneficiaries have below-basic health literacy, making it more essential to tailor educational efforts to diverse populations. Unfortunately, many existing health education resources cater to a small, privileged subset of patients, leaving many others uninformed. Despite this, 94 % of people want health education materials from their doctors, yet fewer than a third of physicians provide them. To empower patients in their healthcare decisions, we must prioritize accessible, patient-centered education. This means ensuring that every patient has the knowledge and opportunity to make an informed choice about OS—rather than having the decision made for her.

In conclusion, Cook and colleagues shed light on a powerful opportunity to reduce the burden of ovarian cancer through building collaboration between surgical specialties. Their work supports integrating OS more broadly into surgical practice provided that this can be done without appreciably increasing costs, operative complexity or morbidity. Ongoing prospective studies will help define best practices. Continued advocacy for updated coding and universal coverage is critical to ensuring equitable access. Additionally, efforts to enhance knowledge dissemination are key to empowering patients to drive change and make informed decisions about their care.

Disclosures

XMG – Intuitive: educational funding

KCF – AstraZeneca: educational funding, Immunogen: advisory fees; Merck: grant funding; Genentech: grant funding

RS – Break Through Cancer Foundation: grant funding; Pacira Pharmaceuticals: grant funding; AstraZeneca: research consulting; Gray Foundation: grant funding; visiting professorship appointment at MIT