In her opening remarks to the Committee, Dr. Hanley recommended the use of a procedure called an opportunistic salpingectomy. This is the removal of fallopian tubes as part of another pelvic surgery to decrease the risk of high-grade serous carcinoma. Among the various types of ovarian cancer, she said, high-grade serous carcinoma is the most common (70% of all cases) and lethal (90% of all deaths).

Dr. Hanley noted that it has been known for some 20 years that most high-grade serous cancers start in the fallopian tubes. After child-bearing, the fallopian tubes play no known role. In contrast, the ovaries continue to produce hormones that are important for a woman's long-term health. This led her team in British Columbia to recommend a salpingectomy (removal of fallopian tubes) at the same time as a hysterectomy (removal of the uterus) or a salpingectomy instead of tubal ligation (having the tubes tied). The goal was to take the opportunity presented by a gynecologic surgery to do a salpingectomy and thereby reduce the risk of ovarian cancer.

Despite compelling data on the safety and feasibility of opportunistic salpingectomy, Dr. Hanley noted that between 2017 and 2020, nearly 80,000 Canadians who received a tubal ligation or hysterectomy had not had an opportunistic salpingectomy. In her words, this represented "a missed opportunity to stop ovarian cancer from developing."

Seventy per cent of ovarian cancers and 90% of deaths from ovarian cancer are from the high-grade serous type. Approximately 20 years ago, we discovered that most high-grade serous cancers arise in the Fallopian tube and not on the ovary, as was previously believed. Fallopian tubes connect the ovaries to the uterus, but they play no known role post-childbearing. This is not true of ovaries, which produce endogenous hormones that are important for women's long-term health. Thus, taking the opportunity to remove the Fallopian tubes during other gynecological and pelvic surgeries while leaving the ovaries behind has been a ground-breaking ovarian cancer prevention approach.

In 2010, our team in British Columbia launched the world's first population-based ovarian cancer prevention program. We recommended that salpingectomy, the removal of both Fallopian tubes, be performed at the time of hysterectomy, the removal of the uterus. We also recommended removal of Fallopian tubes rather than ligation or having one's tubes tied for permanent contraception. Recognizing that approximately 80% of ovarian cancers occur in people who have no genetically increased risk, we based this prevention effort not on risk for ovarian cancer but rather on opportunity. Hence, we called it opportunistic salpingectomy. We are taking an opportunity provided by another surgery to also conduct this important ovarian-cancer prevention strategy. This is now recommended practice in nine countries worldwide, including Canada. Through research, we've demonstrated the safety and feasibility of opportunistic salpingectomy, and in 2022, we provided the first evidence that removing Fallopian tubes does significantly reduce risk for ovarian cancer.

Despite these compelling data, a recent assessment of the pan-Canadian practice of Fallopian tube removal demonstrated considerable variation in uptake outside of B.C. The study estimated that between 2017 and 2020, nearly 80,000 Canadians received a tubal ligation or hysterectomy without Fallopian tube removal, representing a missed opportunity to stop ovarian cancer from developing and translating to a possible 1,000 future cases of ovarian cancer that could have been prevented.

In response to a question from a Committee member, Dr. Salvador provided additional recommendations for women who have a family history of ovarian cancer. She said that they usually recommend to such women to have both their fallopian tubes and ovaries removed "10 years before an incidental cancer in their family or as soon as they are done child-bearing."

Typically, for ovarian cancer, we're usually asking women who have that cancer history with family members to go ahead and remove Fallopian tubes and ovaries at a minimum of about 10 years before an incidental cancer in their family or as soon as they are done child-bearing. The reason we say this is that ovarian cancer is so difficult to treat. You do not want to miss an opportunity to intercede and remove those cancers.

Dr. McAlpine noted that 80% of ovarian cancer patients do not have a known inherited mutation in a gene, such as the breast cancer (BRCA) gene. Individuals with no family history of the disease and no known presence of a gene mutation linked to the disease are considered to be of general risk for ovarian cancer.

While the initial focus of opportunistic salpingectomies was gynecologic surgeries, such as hysterectomies and tubal ligation, Dr. McAlpine noted that they are now broadening their focus to any surgery in the abdomen. She gave the example of a gallbladder surgery or a colorectal procedure.

We talked a lot about BRCA. That's 20% of high-grade, serious ovarian cancers. That leaves 80% of patients who don't have a family history who are out in the community. They are what we call general risk. That's where we think we need to actually put our energies and motivation. When those individuals are having a surgery in their abdomen, we've moved from focusing initially on gynecologic surgeries: If you're getting a hysterectomy but they're going to leave the tubes, why don't you remove the tubes so that the cancer never develops?

We're also now moving into the general surgery forum. If you're getting gallbladder surgery or a colorectal procedure, your tubes are there and they are accessible. You have a skilled surgeon in the room. Can we remove those tubes so that the individual, 15 years later, doesn't develop ovarian cancer?

Dr. Salvador made a similar comment, noting that "it's actually a fairly easy thing to add to a surgery that's being done anywhere near the pelvis," including a vaginal hysterectomy.

The nice thing about a salpingectomy...is it's actually a fairly easy thing to add to a surgery that's being done anywhere near the pelvis. That's why they're branching out in their colorectal and general surgery teams, because if you're there to take out an appendix, it's a pretty easy thing to also pop out a couple of Fallopian tubes while you're down there. Even at the time of doing a vaginal hysterectomy, it's fairly easy to move the Fallopian tubes into the vagina to be able remove them safely and allow the ovaries to stay behind.

In response to a question from the Committee, Dr. Hanley shared the results of the first prospective study of opportunistic salpingectomy done for the purpose of ovarian cancer prevention. In the approximately 26,000 people who had had an opportunistic salpingectomy, they saw 0 cases of high-grade serous cancers. She noted: "This was statistically significantly lower than the number that we would have expected to see."

Dr. Hanley contrasted that result with the control group, who were people who had had hysterectomies alone, leaving their fallopian tubes intact, or people who had had tubal ligations, meaning their tubes were tied rather than removed. Among the approximately 32,000 people in this group, they found 15 cancers.

However—noting that the average age of diagnosis for ovarian cancer is 61—Dr. Hanley added that the results are "not reflective of the number of cancers we expect to prevent." The average age of the people in the two groups was just over 40—"nowhere near...the upward age of diagnosis of ovarian cancer." Nevertheless, she said, "we've already seen the statistically significant difference in these groups at this very early stage, so that's very promising in terms of the risk reduction that we can expect."

As you may be aware, the average age of diagnosis for ovarian cancer is 61. We actually do these opportunistic salpingectomies on people who on average are in their early forties. We haven't had all the follow-up time that we need to really answer that question.

Our 2022 article in JAMA Network Open [Outcomes From Opportunistic Salpingectomy for Ovarian Cancer Prevention] was the first prospective study of opportunistic salpingectomy done for the purpose of ovarian cancer prevention. It is important, because it means the surgeon is removing the entire fimbriated end of that Fallopian tube to really reduce the risk.

In that study, we saw zero high-grade serous cancers in the approximately 26,000 people who had an opportunistic salpingectomy. This was statistically significantly lower than the number that we would have expected to see if the cancers had been arising at the same rate as they were in the control groups, which were people who had hysterectomy or tubal ligation alone.

We haven't had enough follow-up time to give the specific number needed to treat, but we have a lot of preliminary evidence that suggests that opportunistic salpingectomy is going to be very effective at reducing the risk of high-grade serous ovarian cancers.

Yes, for the control group, we included basically the surgeries that women would have gotten prior to the recommendation that salpingectomy be included. Those were women who had hysterectomies alone, so their Fallopian tubes got left behind, or women who had tubal ligations, so their Fallopian tubes were tied rather than removed. That was our control group. There were 32,000 of them, and there were 15 cancers in that group.

Again, because these women are still quite young, this is not reflective of the number of cancers we expect to prevent. The average ages in these groups were 42 in the salpingectomy group and 41 in the other group, so we're nowhere near, with the follow-up that we have, the upward age of diagnosis of ovarian cancer. However, we've already seen the statistically significant difference in these groups at this very early stage, so that's very promising in terms of the risk reduction that we can expect.

In her opening remarks, Ovarian Cancer Canada CEO Tania Vrionis advocated for genetic testing to identify people at higher risk of ovarian cancer. She told the Committee: "With an estimated 20% to 25% of ovarian cancers known to be hereditary, identifying those at risk through genetic testing and offering preventative or risk-reducing options will have a significant impact on saving lives now."

She noted that Ovarian Cancer Canada and its partners had identified inequities regarding access to genetic testing. She called for timely and equitable access to genetic testing to identify individuals at risk for ovarian cancer "to stop ovarian cancer before it starts."

With an estimated 20% to 25% of ovarian cancers known to be hereditary, identifying those at risk through genetic testing and offering preventative or risk-reducing options will have a significant impact on saving lives now.

Ovarian Cancer Canada and our partners have revealed gaps and inequities regarding access to genetic testing including but not limited to regional variations in criteria and wait times, under-representation of individuals of Asian or indigenous origin, and racialized and ethnic individuals being less likely to be referred for genetic testing and more likely to receive inconclusive genetic test results.

We must maximize and optimize the identification of individuals at increased risk for ovarian cancer through timely and equitable access to genetic testing to stop ovarian cancer before it starts.

Dr. Hanley made similar observations about the need for genetic testing. She stated that genetic mutations are often identified only when ovarian cancer has been diagnosed. She said that they are working hard to get genetic mutations identified through testing before cancer is diagnosed.

There is a lot of interesting research happening on how to get people the testing they need as early as we possibly can in order to prevent the 20% to 25% of ovarian cancers in BRCA-mutated people. It should be preventable if we detect those mutations earlier. Unfortunately, often these mutations are being detected at the time of cancer diagnosis. We're really working very hard on ways that we can offer this testing to get those mutation results detected before any cancer has been diagnosed.

Dr. Salvador commented that ovarian cancer tumours are tested after surgery. If a patient tests positive for a genetic mutation, such as BRCA, they are encouraged to reach out to blood family members so that they can get genetic testing as well.

Dr. Salvador also noted that more individuals with breast cancer are getting access to BRCA testing. While access to the testing used to be fairly strict, she said, provinces are expanding genetic testing for breast cancer patients.

And it's not just ovarian cancer and breast cancer that can be linked to an inherited genetic mutation. Dr. Salvador mentioned that endometrial (uterine) cancer can have an inherited genetic link, namely, Lynch syndrome. She said that "About 80% of Lynch syndrome family members can get endometrial cancer." She also noted that while most people associate Lynch syndrome with colon cancer, the link to endometrial cancer is just as strong.

It's becoming much more permissible to get BRCA testing in breast cancer. It actually used to be fairly strict, and now they realize they should really be augmenting who can get tested. Most programs in each province are opening up about really maximizing the testing.

For breast cancers, they are often doing it with blood testing, but what's interesting is that for our ovarian cancers that are at risk, we actually do tumour testing. We test the tumour itself when we're doing their surgeries. Then, once we know that a particular individual is testing positive for BRCA, whether it's in breast or ovarian cancer, we've been working very hard to try to maximize reaching out to family members and making sure that they know to contact pertinent blood family members so that they can come in and also get testing as well. The best thing we can do for anyone is prevention, by far.

Endometrial cancer is also another cancer that can be genetically related through Lynch syndrome. People don't realize how strong a connection that is. About 80% of Lynch syndrome family members can get endometrial cancer. Most people associate it with colon cancer, but the connection is actually just as strong for endometrial cancer.

In her opening remarks, Dr. Salvador highlighted three areas of concern for the Society of Gynecologic Oncology of Canada (GOC). One was what she called "the backsliding of performance in our prevention of cervical cancer." She pointed to a 2023 report by the Government of Canada and the Canadian Cancer Society that revealed that cervical cancer is the fastest-growing cancer in women, rising at a rate of 3.7% annually since 2015.

Though it is well known that the human papillomavirus (HPV) is the primary cause of cervical cancer and a vaccine has been available in Canada since the 1990s, the vaccination rate is on the decline, she said. She called for a nationwide campaign to increase awareness of HPV and to encourage uptake of the vaccine.

A report was published in November 2023 by the Government of Canada with the Canadian Cancer Society on Canadian cancer statistics. It identified cervical cancer as the fastest-growing cancer in women, with incidence rising at a rate of 3.7% per year since 2015. Frankly, to me this is shocking, because women should have easy access to effective cervical cancer prevention strategies in Canada.

Primary prevention via vaccination against the human papillomavirus, or HPV, is offered to school children in every province, as well as to women up to the age of 45, and it has been available in Canada since the 1990s, yet there are decreasing vaccination uptake rates in our population. HPV is the primary cause of cervical cancer as well as vulva, anal and throat cancer. GOC strongly recommends nationwide campaigns to increase the awareness of the burden of HPV and to help increase those vaccination uptake rates. There's also secondary prevention via screening through HPV and pap testing. Unfortunately, our most vulnerable populations are in locations that do not have an organized province-wide screening program yet, or easy access to health care professionals who offer screening, leading to disparities in identification and treatment of these precancerous cervical lesions.

One possible reason for the decline in vaccination uptake is a drop off in public education. Dr. Salvador told the Committee that when the HPV vaccine was introduced, "there were massive nationwide campaigns." Every 10 years, she said, a new generation of families is making decisions about vaccination. And the risks associated with HPV are not just cervical cancer, she noted, adding that vulvar, anal and throat cancers are also associated with HPV.

When I was growing up and HPV was first discovered, and then the vaccinations first came out, there were massive nationwide campaigns. I remember them, when I was in my 20s going into my 30s, as they were doing these campaigns.

I've noticed that there seems to be a lack of these campaigns nowadays. We have to keep in mind that every family that is making a decision on whether or not to vaccinate their child changes every 10 years. You're dealing with a new generation that's going into their child-bearing years and making decisions about having children....

It's not just cervix. It's vulvar, anal and throat. It's actually quite a large cancer burden when you look at it. We need to constantly stay on top of the educational component for our Canadian population.

Cervical cancer prevention relies not just on vaccination against HPV, but on screening as well. Pap tests—which have traditionally been used to screen for cervical cancer—look for changes in the cervix caused by the HPV, Dr. Salvador explained. In other words, pap tests look for an active lesion.

HPV tests, on the other hand, detect the presence of an active virus, potentially before any lesions occur, she said.

What a Pap test looks for are changes that the HPV virus has caused in the cervix, so it looks for an active lesion. What the HPV tests looks for is an active virus, so it can be more specific and sensitive to be able to identify someone who has an active HPV virus. Not only that, but there are different subtypes of HPV. We know some of them are more likely to cause more aggressive cancers than others.

We can subtype these now. If we find out that someone has an HPV virus, there are guidelines that were just published last year about this in combination with GOC, CPAC [Canadian Partnership Against Cancer] and the Canadian colposcopy society. This was all put together through Canada-wide recommendations for HPV testing, as well as what to do when someone has a positive HPV test.

In response to a question from the Committee, Dr. Salvador recommended more screening for the presence of HPV, either by healthcare professionals or by individuals, using self-testing.

We need to support for better provincial-based screening programs for cervical cancer in areas that are not on track to reach our goal of cervical cancer elimination, either through improved access to health care professionals providing screening or through access to HPV self-testing, as offered in some countries and as currently being highlighted in British Columbia.

In her opening remarks to the Committee, Dr. McAlpine highlighted opportunities to better treat endometrial (uterine) cancer through molecular testing. She stated that endometrial (uterine) cancer is the most common gynecological cancer and its incidence is on the rise.

About 10 years ago, she and her colleagues recognized that there was little consensus on the disease, "meaning that a patient could get a completely different diagnosis from two different pathologists, directing them, for example, to six months of radiation or chemotherapy or to no treatment at all."

They developed a system that could classify endometrial tumours into subtypes. "They could identify which patients were most likely to have their disease recur and which patients were most likely to have an inherited cancer syndrome, and they could determine which treatments worked best," Dr. McAlpine said.

Despite the fact that the classification system was adopted by the World Health Organization and is now considered the standard of care globally, "molecular classification is not uniformly available to patients across Canada," she stated. "They may have to send their tissue out of province to get molecular testing. Molecular testing may never even be discussed with patients. Essentially, endometrial cancer has had one of the worst examples of health care inequities of any cancer."

Her recommendation to the Committee was "to ensure that scientifically proven, value-added initiatives in prevention, diagnosis, screening and treatment of gynecological cancers are available to all Canadians" by, for example, funding molecular testing for endometrial cancers across the country.

Endometrial or uterine cancer is the most common gynecological cancer. Globally, it is increasing in both incidence and mortality, and it's on a trajectory to be the second most common cancer that women—including gender-diverse, trans and non-binary individuals—are likely to develop in their lifetimes. Despite these statistics, there has been little research, attention or funding related to endometrial cancer. It receives about a fifth of what prostate and breast cancer research receive.

Beginning about 10 years ago, we recognized that the way endometrial cancers were being categorized and subsequently managed was not working. There was little consensus between expert pathologists and their diagnostic reporting, meaning that a patient could get a completely different diagnosis from two different pathologists, directing them, for example, to six months of radiation or chemotherapy or to no treatment at all.

Clearly, this way of managing it was unacceptable. Our team worked to change this. We identified key molecular features in endometrial tumours that could be determined by simple methods that are achievable in most hospitals already. Within five years, we created a system that could consistently classify tumours and form molecular subtypes. They could identify which patients were most likely to have their disease recur and which patients were most likely to have an inherited cancer syndrome, and they could determine which treatments worked best.

Our classification system was adopted by the World Health Organization in 2020, and it was immediately implemented into international treatment guidelines. It is now considered the standard of care globally.

What is tremendously frustrating is that despite the international recognition, molecular classification is not uniformly available to patients across Canada. Even in British Columbia, where we developed this tool, it took two years for us to assure free testing for all endometrial cancer patients. In Canada, we have centres where they may actually have to wait eight to 10 weeks for their results. They may have to send their tissue out of province to get molecular testing. Molecular testing may never even be discussed with patients. Essentially, endometrial cancer has had one of the worst examples of health care inequities of any cancer. Our team is passionate about changing this.

My call to action is to first work to ensure that scientifically proven, value-added initiatives in prevention, diagnosis, screening and treatment of gynecological cancers are available to all Canadians. This could be by supporting provinces, for example, to fund molecular testing for endometrial cancers across Canada. We must change the current reality in this country that how you are treated depends on where you're diagnosed and must instead ensure equity for all.

In response to a question from the Committee, Dr. McAlpine provided additional information on molecular testing in endometrial cancer. Molecular testing of a tumour could help to determine the course of treatment, whether surgery alone or surgery plus additional treatment. Dr. McAlpine stated: "there are opportunities to intervene and cure, and there are opportunities to spare treatment."

The endometrial cancer I was talking about is one that might present with spotting. It very much depends on the molecular features of that tumour and whether it is a cancer confined to the uterus and cured by surgery alone or is identified by that molecular feature and definitely needs more treatment because of a very high risk of recurrence.

In knowing that, there are opportunities to intervene and cure, and there are opportunities to spare treatment just in those two examples.