0:00

Welcome to Public Health

0:02

on Call, a podcast from

0:04

the Johns Hopkins Bloomberg School

0:06

of Public Health, where

0:09

we bring evidence, experience,

0:11

and perspective to make sense

0:13

of today's leading health challenges.

0:15

If you have questions or

0:18

ideas for us, please send

0:20

an email to Public Health

0:22

Question at JHU.EDU. That's Public

0:25

Health Question at JHU. EDU.

0:27

for future podcast episodes. Hi

0:29

listeners, it's Lindsay Smith-Rogers. Today,

0:32

a look at preventing ovarian

0:34

cancer, which can be difficult

0:36

to diagnose and treat. Stephanie

0:38

Desmond talks to Dr. Rebecca

0:40

Stone, the director of gynecologic

0:42

oncology at Johns Hopkins, about

0:44

changes in how we understand

0:46

ovarian cancer, that much of

0:49

what is called ovarian cancer

0:51

may actually start in the

0:53

fallopian tubes. and about an

0:55

under-use surgery that preserves ovaries

0:57

and may save lives. Let's

0:59

listen. Rebecca Stone, thanks so

1:01

much for joining me. Thank you so

1:03

much for having me. It's a real

1:05

pleasure. So today I want to

1:07

talk about something with a difficult

1:10

name to say, but it actually

1:12

could save a lot of people's

1:14

lives. So we're talking about salpingectomy,

1:16

which is the removal of the

1:19

fallopian tubes, and I understand that

1:21

this could really... a game changer

1:23

in ovarian cancer. Could you talk

1:25

to me a little bit about,

1:27

maybe about, let's start with ovarian

1:29

cancer, right? It's hard to screen

1:31

war and it's deadly, and this

1:33

can reduce the risk. Tell me,

1:35

please. I think sometimes when I talk

1:38

to people about this, the first thing,

1:40

they're thinking is, well, okay,

1:42

you're talking to me about ovarian

1:44

cancer, and then you're talking about

1:46

a structure that's not the

1:48

ovary. You're talking about the

1:50

fallopian tube, and so How do you

1:53

make sense of those two things? And

1:55

this is the fact that we're

1:57

talking about the fallopian tube is

1:59

real. to a

2:01

relatively recent scientific discovery that

2:03

a large number of ovarian

2:05

cancers or types of cancer

2:07

that we have historically called

2:09

ovarian cancer actually originate either

2:11

directly or indirectly from the

2:13

fallopian tube and you know

2:15

many people have not thought

2:17

about gynecologic anatomy or function

2:20

ever or maybe it was

2:22

many many years ago but

2:24

you may remember the fallopian

2:26

tube is this small thin

2:28

structure that arises from the

2:30

top of the uterus or

2:32

the womb and sits immediately

2:34

adjacent to the ovary and

2:36

so when the ovary produces

2:38

an egg the fallopian tube

2:40

grabs that egg and the

2:42

egg goes into the tube

2:44

and then maybe if it

2:46

meets a sperm there, there's

2:48

fertilization event and then pregnancy

2:50

can happen. And so you

2:52

can imagine that if when

2:54

a cancer starts in either

2:56

the fallopian tube or ovary,

2:58

it sometimes might be hard

3:00

to discern, you know, which

3:02

was truly the primary site

3:04

of the cancer because they're

3:06

so, you know, they're, we

3:09

always say they're frenemies or

3:11

they live so, you know,

3:13

they live so, you know,

3:15

closely next to each other.

3:17

And so, you know, in

3:19

medicine historically, there has been

3:21

a group of cancers that

3:23

we have called ovarian cancer.

3:25

And I tell people, maybe

3:27

it helps to think about

3:29

the ovary sort of like

3:31

a grape. And you might

3:33

think a grape sort of

3:35

has three layers. It has

3:37

the skin of the grape,

3:39

the fruit of the grape,

3:41

and then the seed, like

3:43

the germanal center. and traditionally

3:45

ovarian cancers have been attributed

3:47

to one of those three

3:49

layers. With the most, the

3:51

highest prevalence or most common

3:53

types of rising... from what

3:55

people thought to be from

3:57

the skin of the grape.

4:00

And that maybe is like

4:02

90% of ovarian cancers historically

4:04

were attributed to the skin

4:06

of the grape and only

4:08

about 10% to the fruit

4:10

or the sea, the Germanal

4:12

center. But as you know,

4:14

people have really studied ovarian

4:16

cancer and looked at, you

4:18

know, what do the cells

4:20

look like under the microscope?

4:22

and we've started to learn

4:24

more about, particularly about people

4:26

and families that have this

4:28

hereditary risk of ovarian cancer,

4:30

we really have come to

4:32

accept that many of the

4:34

cancers that we thought arose

4:36

from the skin of the

4:38

grape, the surface of the

4:40

ovary, actually appear to come

4:42

from the end of the

4:44

fallopian tube that sits right

4:46

next to the ovary. And

4:48

so if you Google ovarian

4:51

cancer... you will often see

4:53

pictures of and read about

4:55

a type called high-grade cirrus

4:57

cancer, which is the most

4:59

common and deadly type of

5:01

cancer that people had traditionally

5:03

attributed to the ovary. In

5:05

most cases, it comes from

5:07

that end of the fallopian

5:09

tube. So, that then brings

5:11

us to, you know, why

5:13

are people talking about the

5:15

fallopian tube so much because...

5:17

Now that we really understand

5:19

that most types of ovarian

5:21

cancer, most cases of ovarian

5:23

cancer are starting in the

5:25

tube instead of the ovary,

5:27

explains why in medicine we've

5:29

never been able to develop

5:31

a screening test because, you

5:33

know, many of our screening

5:35

tests have relied on imaging,

5:37

like ultrasound, but there really

5:40

is no imaging in medicine

5:42

that can routinely see a

5:44

fallopian tube. Which is shocking

5:46

to most people. I mean,

5:48

it was sort of shocking

5:50

to me, and I'm a

5:52

doctor, right? And I've, you

5:54

know, this has been an

5:56

area of interest of mine

5:58

for many, many years. And

6:00

when you really sit down

6:02

and think about it, the

6:04

fact that we actually don't

6:07

have imaging for a critical

6:09

structure in the body, like the

6:11

fallopian tube, is surprising.

6:13

So what do we do about that?

6:15

I think this is the question of

6:18

the day, right, which is if we

6:20

can't screen for ovarian cancer, right,

6:22

with imaging or blood tests,

6:25

and it's a cancer that

6:27

we don't have... a reliable

6:29

way to eradicate, meaning we

6:31

can't cure it in many cases,

6:33

it's very dangerous, then is

6:36

there something that we could do

6:38

to prevent it? You know, when you

6:40

think about the option for prevention

6:42

being ovarian removal, well that's

6:45

not so great because the

6:47

ovaries are an important endocrine

6:49

organ, probably well past menopause,

6:52

and this is a real

6:54

active area of research. So,

6:56

you know, the idea that we

6:58

could prevent a cancer by removing

7:01

the ovaries is not so exciting,

7:03

but knowing that to prevent

7:05

ovarian cancer or many

7:07

cases of ovarian cancer

7:09

in a way that doesn't involve

7:11

removing the ovaries, but

7:13

rather the fallopian tube, which

7:16

in medicine doesn't have any

7:18

known form or function once

7:20

a person has completed

7:22

family planning. Well, that's actually

7:25

a more interesting idea

7:27

because the fallopian tube

7:29

doesn't make any hormones like the

7:31

ovary and its job in life

7:34

is to help with pregnancy. And

7:36

so if either someone doesn't want

7:39

pregnancy or they're never

7:41

planning on pregnancy, then

7:43

removal of the fallopian tube can

7:45

be a very good option

7:47

for prevention of... this

7:49

type of cancer that has a

7:51

misnomer now, right? We've called it

7:54

ovarian cancer, when in fact it

7:56

is largely fallopian tube cancer. And,

7:58

you know, the next most... common people

8:00

ask, question people ask is like,

8:02

well, how successful is this? Right?

8:04

How good is this as a

8:07

preventive strategy? And so I tell

8:09

people, well, when you think about

8:11

the most common and deadly type

8:13

of ovarian cancer, this type called

8:15

high grade cirrus, fallopian tube removal

8:17

right now, based upon existing data,

8:20

it's projected to prevent about 80

8:22

% of those cases, which is

8:24

just like amazing. And when you

8:26

think about ovarian cancer in general,

8:28

memory told you, not all not

8:31

all cancers come from the fallopian

8:33

tube. Some still primarily come from

8:35

the ovary. If you were to

8:37

look at what fraction of ovarian

8:39

cancer in general does fallopian tube

8:41

removal prevent, it's probably on the

8:44

order of maybe 50 to 65%.

8:46

So still the majority, which is,

8:48

which is very impressive. And it's

8:50

a procedure that is generally speaking,

8:52

you know, can be done as

8:55

standalone outpatient surgery. It could be

8:57

done in lieu of like a

8:59

tubal ligation, right, which is probably

9:01

the most common time in a

9:03

person's life when they might be

9:05

considering a self -inject me, fallopian tube

9:08

removal. You're thinking about getting your

9:10

tubes tied or it can be

9:12

a procedure that is done at

9:14

the same time as another procedure.

9:16

And that's often called opportunistic, meaning

9:19

taking the opportunity to offer somebody

9:21

preventative surgery. Or ovarian cancer. So

9:23

it could be done at hysterectomy

9:25

or people are starting to think

9:27

about what are the other scenarios

9:29

when it could be done. And

9:32

lots of people have surgery on

9:34

their abdomen in their, we say

9:36

post reproductive years. So they have

9:38

hernia, a pair, is it maybe

9:40

their gallbladder out or more other

9:43

procedures when, if they knew this

9:45

was an option, they might know

9:47

they could ask their surgeon about,

9:49

about the chance. So this is

9:51

not commonly known though. Tell me

9:53

about why we don't know much

9:56

about this. And also you make

9:58

it sound super easy. And I

10:00

imagine. it's not as easy as you've just made it

10:02

sound. It's not so hard but you

10:04

know I think there are lots of

10:07

considerations and we could talk briefly about

10:09

those. I think the first question is

10:11

why don't people know about this and

10:13

and a lot of people you know

10:15

they're kind of what's the word you know

10:18

shocked and surprised that they don't know

10:20

about this because it seems like such

10:22

an important discovery and it is you

10:25

know in health. Really, this has

10:27

been something that has been

10:29

embraced in the field of

10:31

OBGYN, particularly when thinking about

10:33

taking the opportunity to reduce

10:35

risk at the time of

10:37

like a hysterectomy. But

10:39

beyond that, people have not

10:42

really committed to creating, you

10:44

know, knowledge mobilization around this for

10:46

whatever reason. I mean, primarily, you

10:48

know, we're not good at this

10:51

in medicine, right? We're not good

10:53

at... conveying complex things

10:55

or telling people about

10:57

new scientific discovery. It's

11:00

just something that medicine

11:02

has not done well,

11:04

unfortunately. And there are some

11:07

barriers to implementing this in

11:09

the field of OBGYN and

11:11

then into surgical practice more

11:13

broadly. You know, in the

11:15

field of OBGYN, I had mentioned

11:17

one of the most common

11:20

times that a person might

11:22

consider a salpingectomy would be

11:24

at the time of permanent

11:26

contraception, right? So tubalagation. There

11:28

are some structural barriers to

11:30

being able to have access to

11:32

or to choose a salpingectomy instead

11:34

of a tubalagation. One of them,

11:37

you know, being like, for instance,

11:39

in our state and in a

11:41

number of other states, there's outdated

11:43

health policy. And there's also

11:45

not a insurance infrastructure

11:48

that is fail safe

11:50

to guarantee coverage. And that's

11:52

something that you know we are

11:54

really working on a lot of

11:57

advocacy to address. And then in

11:59

terms of translating this into surgical

12:01

practice more broadly, that has a

12:03

lot of important considerations. You know,

12:06

one being that it shouldn't be

12:08

something that a woman, we think,

12:10

or a person hears about for

12:13

the first time, you know, when

12:15

they are needing to have their

12:17

gallbladder out, right? This is really

12:19

something that someone should hear about,

12:22

you know, during their engagement in

12:24

their health throughout their lifetime. really

12:26

hasn't happened. Right now I think

12:29

people are thinking, okay, well, you

12:31

know, if a person needs X,

12:33

Y, Z procedure, you know, they

12:36

could, like they're coming into the

12:38

doctor for it or, you know,

12:40

God forbid they're in their emergency

12:42

or whatever, you know, they could

12:45

receive counseling about this at that

12:47

time, but it's not the most

12:49

ideal time for something like that

12:52

to happen. And it's better if

12:54

people have heard about this throughout

12:56

their health journey and they're prepared.

12:59

consider having a tubalagation for instance

13:01

and I think I might prefer

13:03

a cell conjectony instead or if

13:06

I need a hysterectomy I know

13:08

to talk to my doctor about

13:10

this or I know that if

13:12

I end up in my post-reproductive

13:15

years needing surgery for something that

13:17

I would like to also have

13:19

this. So it's sort of something

13:22

that the patient plans and they're

13:24

empowered to plan and choose. And

13:26

the other reason is that there

13:29

haven't been a lot of education

13:31

materials created about this in OBGYN,

13:33

let alone materials that could be

13:35

used by doctors that are non-obGYN

13:38

doctors who are not familiar with

13:40

counseling people about reproductive anatomy and

13:42

physiology and alternatives even, right? I

13:45

think that the alternatives part of

13:47

it is also really important because

13:49

there are options besides surgery to

13:52

decrease the risk of ovarian cancer.

13:54

For instance, we've known for a

13:56

long time that when people take

13:58

birth control pills, particularly for a

14:01

prolonged period of time or for

14:03

at least five years in their

14:05

life, that that decreases the risk

14:08

of ovarian cancer as well, probably

14:10

upwards of 40 to 50%. So

14:12

if somebody were to have, for

14:15

example, an ovarian cancer gene, this

14:17

could really be a solution that

14:19

is less damaging than, say removing

14:22

the ovaries. Yeah, so I think

14:24

what you're asking is if you

14:26

have had genetic testing due to

14:28

typically a family history, right, where

14:31

there are a number of people

14:33

who have been affected by breast

14:35

cancer, ovarian cancer, sometimes pancreatic cancer,

14:38

or colon cancer, what about the

14:40

option of removing the fallopian tube

14:42

instead of the ovary, for instance?

14:45

And I think that's a really

14:47

good question. That's something that that

14:49

is being studied right now. And

14:51

as you pointed out, the standard

14:54

of care for people who have

14:56

a high risk of developing ovarian

14:58

cancer in their lifetime due to

15:01

a gene mutation, for instance, and

15:03

these people, you know, have upwards

15:05

of a 40% chance of developing

15:08

ovarian cancer by age 80, the

15:10

standard of care has been removal

15:12

of the ovaries. And really, the

15:14

fallopian tube was just along for

15:17

the ride, right, when this started

15:19

in the early 2000s. you know

15:21

people would remove the ovary, the

15:24

fallopian tube would be removed as

15:26

well because there's no point in

15:28

keeping the fallopian tube if you're

15:31

taking the ovaries out and they

15:33

share a blood supply and people

15:35

would look at the ovary and

15:37

they couldn't never find any evidence

15:40

that ovarian cancer started there until

15:42

people started looking at the fallopian

15:44

tube and so really from this

15:47

emerged the idea of you know

15:49

maybe we were going about it

15:51

all wrong and We actually need

15:54

to focus on fallopian tube removal

15:56

instead of ovarian removal. But we

15:58

don't know for sure yet. And

16:01

we know that risk reducing surgery

16:03

as it has been done since

16:05

early 2000. which means removal of

16:07

the tube and the ovary on

16:10

both sides, is highly effective at

16:12

preventing ovarian cancer. You know, anywhere

16:14

between near 100% to somewhat less

16:17

than that, depending upon what's found

16:19

in the fallopian tube at the

16:21

time of risk-producing surgery. But we

16:24

don't know how effective it is

16:26

to just have the fallopian tube

16:28

out and to keep the ovary.

16:30

or to do what's called a

16:33

stage surgery where you have the

16:35

fallopian tubes out as soon as

16:37

you've completed family planning and you

16:40

wait to have the ovaries out

16:42

until you're closer to the natural

16:44

age of metapoles. What is your

16:47

aim here? So my aim, I'm

16:49

a person who takes care of

16:51

a lot of patients and families

16:53

who are affected by this disease

16:56

and who suffer from this disease

16:58

and die from it. And it

17:00

has really been one of the

17:03

most important areas of clinical medicine

17:05

for me throughout my life. And

17:07

I've dedicated countless hours and love

17:10

and devotion to it. And sitting

17:12

honestly with my patients, many patients

17:14

who are suffering from this, their

17:17

life, I have promised them that

17:19

I would continue to work on.

17:21

developing opportunities to prevent the disease,

17:23

truly like in their honor. And

17:26

that is literally what motivates me.

17:28

And you know, it's gotten to

17:30

the point, Stephanie, where I honestly

17:33

couldn't sleep anymore, knowing that, you

17:35

know, so many people in the

17:37

United States have an opportunity to

17:40

know about this and to choose

17:42

it, right? Because people actually choose

17:44

to litigation more than any. other

17:46

method of family planning in the

17:49

United States. Lots of people have

17:51

hysterectomies and other surgeries where, you

17:53

know, if they knew about this,

17:56

they could have the opportunity to...

17:58

bent the disease,

18:01

that people didn't know about this,

18:03

that this was so siloed in the

18:05

field of OBGYN, I

18:07

couldn't sleep anymore about it. And so I just

18:09

decided I was just gonna work on it and

18:11

for the rest of my life until I got

18:14

as far as I could. So you're

18:16

out here spreading the word. Rebecca Stone, thank

18:18

you so much for your time. Of

18:20

course, thank you so much for having

18:23

me and for really caring about

18:25

this. MUSIC Public

18:29

Health On Call is a

18:31

podcast from the Johns

18:33

Hopkins Bloomberg School of Public

18:35

Health, produced by Joshua

18:37

Sharfstein, Lindsay Smith Rogers, Stephanie

18:39

Desmond, and Grace Fernandez -Sissiri.

18:41

Audio production by J .B.

18:44

Arbogast, Michael Bonfills, Spencer

18:46

Greer, Matthew Martin, and Phillip

18:48

Porter, with support from

18:50

Chip Hickey. Distribution by Nick

18:52

Moran. Production Coordination by

18:54

Catherine Ricardo. Social Media, run

18:56

by Grace Fernandez -Sissiri. Analytics

18:59

by Alisa Rosen.

19:01

If you have questions

19:03

or ideas for

19:05

us, please send an

19:07

email to publichealthquestionatjhu .edu.

19:09

That's publichealthquestionatjhu .edu for

19:11

future podcast episodes. Thank

19:14

you for listening. MUSIC

19:23

.