In early November 2023, several media outlets shared an interesting case report: Several women with a high inherited risk of cancer had opted to have their ovaries removed at the same time as having a caesarean section when having their baby.
Here we look behind the headlines to learn what this procedure is, and who it might be suitable for.
What was this report about?
This piece of work, published in the Journal of Obstetrics and Gynecology, was led by Professor Adam Rosenthal (UCL EGA Institute of Women’s Health and consultant gynaecologist at UCLH).
The four women involved gave birth through caesarean section between 2018 and 2022 were between the ages of 40 and 45. Three had a BRCA1 gene fault and one had a BRCA2 gene fault.
They were all due to have caesarean sections already (two due to expecting twins, two due to previous caesarean births). They were all planning on having their fallopian tubes and ovaries removed (called risk-reducing bilateral salpingo-oophorectomy or RRBSO).
Once their babies were safely delivered, the second part of the surgery took place.
Why were these women planning to have their ovaries removed in the first place?
BRCA1 and BRCA2 gene faults significantly increase a woman’s risk of developing ovarian cancer.
There is no reliable screening tool for ovarian cancer, so the current advice is to have risk-reducing surgery at an appropriate age and when your family is complete. This surgery cuts the chances of developing this cancer by 95%, but also puts the woman into immediate menopause.
Where did these women have the procedures?
The women in the report were all referred to the UCLH Familial Cancer Clinic during pregnancy and received their maternity care at UCLH (University College London Hospitals NHS Foundation Trust).
Did the procedures go well?
Of the four women who had this procedure, none had any major complications and they didn’t need to stay in hospital any longer than they would have if they had had a caesarean section alone.
One of the two women who had not previously had a mastectomy was able to breastfeed her baby.
At follow up afterwards, they reported they were happy they had done the procedure the way they had.
Who would this procedure be suitable for?
The team involved are clear that there are very specific circumstances where this dual procedure would be suitable.
The woman would have to:
Be a BRCA1 gene fault carrier and over 35 years old
Be a BRCA2 gene fault carrier and over 40 years old
Not planning to have any more children
Already have a reason to have a caesarean birth (i.e. they will not perform a caesarean purely because you are planning to have a RRBSO.)
I think this is something that I’d like to do- how do I find out more?
If this is something you are considering, you need to raise this as early as possible with your clinical genetics team.
If you’re already pregnant, you should ask your genetics team or GP to make an urgent referral to your nearest gynaecology team who have experience looking after BRCA carriers. This team will discuss whether this is suitable in your situation and liaise with the obstetric team to put things in place.
It is important to bear in mind that if there is heavy bleeding after delivering the baby, it may not be a safe time to remove the ovaries and fallopian tubes.
If you need an emergency caesarean rather than the planned procedure, it might not be appropriate or possible to have the combined procedure.
It might be helpful to look at the key messages available for patients and healthcare professionals available online.
What’s the final word?
We asked Professor Adam Rosenthal why he is so motivated to do the work he does to improve the lives of women with faulty BRCA genes and he told us: “I enjoy the challenges of explaining complex issues around the origin of ‘ovarian’ cancer and the effects of premature menopause, in the context of the patient’s age and reproductive wishes, to help her make a choices around risk-reducing surgery that she remains happy with. It’s hugely rewarding when a patient expresses relief and satisfaction with having undergone risk-reducing surgery. “
“It’s fantastic that there are dedicated clinicians trying new things to improve the experiences of women living with a high-risk of cancer. Although this isn’t something that will suit every woman considering risk-reducing surgery, the team at UCLH has shown that in these specific circumstances, it is an option to combine these procedures. This is a benefit to these women as it means only one surgery and recovery period.”Ovarian Cancer Action’s Head of Public Affairs and Research, Marie-Claire Platt
Barker, Victoria E. MBChB, MRCOG; Vlachodimitropoulou, Evangelia PhD, MRCOG; O’Brien, Patrick MBBCh, FRCOG; Iskaros, Joseph MSc, FRCOG; Rosenthal, Adam N. PhD, FRCOG. Combined Bilateral Salpingo-oophorectomy and Cesarean Delivery in BRCA1/2 Alteration Carriers: A Case Series. Obstetrics & Gynecology 142(6):p 1500-1503, December 2023. | DOI: 10.1097/AOG.0000000000005423