Should you get a preventative mastectomy like Angelina Jolie?

HOLLYWOOD, CA - FEBRUARY 26:  Actress Angelina Jolie arrives at the 84th Annual Academy Awards at the Hollywood & Highland Center February 26, 2012 in Hollywood, California.  (Photo by Ethan Miller/Getty Images)
Angelina Jolie elected to have surgery after finding out that she has a higher genetic risk for breast cancer. Credit: Ethan Miller/Getty Images

Angelina Jolie made headlines Tuesday by announcing that she had undergone a preventative double mastectomy after testing positive for a mutated BRCA1 gene, which indicates a strong predisposition to breast and ovarian cancers.

In her New York Times op-ed piece, “My medical decision,” Jolie reveals that her doctor estimated she had an 87 percent risk of breast cancer and a 50 percent chance of developing ovarian cancer. “I decided to be proactive and to minimize the risk as much I could,” she writes. Now, post-mastectomy, her risk of breast cancer has dropped to 5 percent. Jolie’s mother died of cancer in 2007 at age 56.

BRCA1 and BRCA2 are two genes that, when mutated, have been linked to breast and ovarian cancers, as well as other types of the disease. Both women and men are susceptible to the faulty genes. Patients can undergo a blood test to see if they have the mutated genes, and genetic counselors can help patients decide on the best course of treatment for them. That might be a prophylactic (preventative) mastectomy, taking drugs like tamoxifen or raloxifene — which are proven to lower breast cancer risk — or simply continuing cancer screenings.

Indeed, the aggressive procedure Jolie had is not for everyone, says Dr. Fred Jacobs, chief medical officer of the eastern division of the American Cancer Society: “That decision needs to be made in conjunction with a very experienced medical oncologist and a genetic counselor who can make sense of the data the woman has.”

“If a woman has a family history which suggested that an evaluation for the BRCA mutation would be medically indicated, and they did it and she had [the mutated gene] — which increased the risk of them getting cancer to a very high number — then it’s a very personal thing,” he adds. “The women who have this issue have a problem with suppressing the development of cancer. Everybody has cell division that may go a little out of whack, but there’s natural body defenses [against that]. This gene suppresses that defense.

“Do you want to live with that risk, or do you want to take aggressive action to reduce it, meaning a rather extensive surgical procedure? [Jolie] spent three months doing it. That requires a bit of a commitment for a disease you don’t have.”

Jacobs also says that Jolie’s procedure does not mean everyone needs to be genetically tested.

“The U.S. Preventive Services Task Force recommend that only women with a strong family history be evaluated for genetic testing, and that only is about 2 percent of adult women in the U.S. But, that is a very large number of women.”

Those who opt for a mastectomy can expect a procedure that takes a few hours, more if the patient opts for reconstructive surgery during the same operation. Patients often choose the simultaneous procedure, Jacobs says, “because they go to sleep and then they wake up and still have breasts.” Reconstructive surgery involves a plastic surgeon recreating the breasts once the breast surgeon has finished his portion of the operation.

Insurance coverage “depends on the policy,” Jacobs says, though he argues that “insurance should cover it because it’s a legitimate form of therapy for a disease process,” when cancer itself has yet to manifest. In the future, Jacobs adds, we “may be able to attack the gene and prevent it from expressing itself in a way that would result in a risk of cancer.” Until then, post-procedure recovery is “like any major surgery, measured in weeks and months.”

Though Jolie greatly reduced her risk from 87 to 5 percent, Dr. Jacobs notes that even that number is still more than the average woman’s risk. “It’s because you can’t remove all the breast tissue in a bi-lateral prophylactic operation,” he says. “Some of the breast tissue is gonna be left behind. We’re gonna take out all that we can, so that her risk is now reduced from 9/10 to 1/20  — that’s a very substantial reduction, but she didn’t reduce her risk to zero.”

Still, Jacobs is quick to commend the actress and director on her decision. “She took the matter into her own hands and said, ‘I’m not gonna sit back and wait for this, I can’t live with that. Other women might be able to, [but] … I want to take charge of my life, and this is available to me.’ It’s a perfectly reasonable thing that she did for herself.”


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