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Angelina Jolie's Decision and You


Article by Dennis R. Holmes, M.D., F.A.C.S.
 
The media has been abuzz with the news that Angelina Jolie recently underwent preventive double mastectomy. As written in her May 14, 2103, New York Times Op-Ed Column, Jolie’s decision to undergo this procedure results from her having been diagnosed as a carrier of a breast cancer gene mutation, called BRCA 1.

Jolie’s disclosure sheds light on the difficult decision that a significant number of women must face every day. BRCA mutations occur in about 1 out of every 500 women in the general population. BRCA mutations are also found in about 1 out of every 20 women diagnosed with breast cancer. Among the 290,000 women expected to be diagnosed with breast cancer in the U.S. in 2013, one can expect that 14,500 will also learn that they, like Jolie, are a BRCA mutation carrier. What are the implications of this diagnosis? On average, BRCA 1 mutations are associated with an 80% lifetime risk of breast cancer and a 40% lifetime risk of ovarian cancer. BRCA 2 mutations have a slightly lower risk (60% lifetime risk of breast cancer and 25% lifetime risk of ovarian cancer), but are also associated with an increased lifetime risk of melanoma, pancreatic cancer, male breast cancer and prostate cancer. BRCA mutation carriers are also more likely to be diagnosed with breast cancer in their 30’s and 40’s as opposed to after age 50 for most non-mutation carriers.

By comparison, the average lifetime risk of cancer for non-BRCA carriers is 13% (about 1 in 8) for breast cancer and 1% for ovarian cancer. Among the 1 in 8 women diagnosed with breast cancer, only about 5% is likely to develop a second cancer in the opposite breast in her lifetime compared to a 60% risk of opposite breast cancer in BRCA mutation carriers.

No doubt, the decision to undergo preventive double mastectomy was a difficult one for Jolie. But a word of caution is in order. Jolie’s decision should not be heard by the general public as a call for double mastectomy for the average woman. Jolie’s particularly genetic circumstances made a double mastectomy a reasonable personal decision for her due to her high risk of developing breast cancer as she grows older. However, 7 out of 8 women will never be diagnosed with breast cancer, and the vast majority of women who are diagnosed with breast cancer can be treated effectively with less extensive surgery that preserves the natural breast with minimal risk of cancer recurrence in either breast. Some BRCA mutation carriers also make the personal decision to utilize increased surveillance (e.g., yearly mammograms and breast MRI) and breast cancer risk reduction measures instead of undergoing preventive double mastectomy.

What one can learn most from Jolie’s decision is that her diagnosis of a BRCA 1 mutation and her decision to undergo preventive double mastectomy came before she was ever diagnosed with breast cancer. Herein lies the greatest value of BRCA testing. It empowers BRCA-mutations carriers to take control of their own health destiny by allowing them opt for preventive surgery or increased surveillance. But it’s by no means an easy decision for most women who must first ask themselves several challenging questions: at what age should I get tested, what should I do if my results show that I am a BRCA mutation carrier, and what will it mean to my health, family, and my self-image?

One critically important message that comes from Jolie’s announcement is the importance of paying attention to your family’s cancer history since it influences your own cancer risk. Jolie’s mother’s diagnosis of ovarian cancer was a clear sign that BRCA gene testing needed to be considered. Similarly, if you have a family or personal history of breast cancer diagnosed before age 50, ovarian cancer, or breast cancer in a male relative, you should speak with your doctor about your family history and seek BRCA testing if you meet criteria. All that is required is a simple blood or mouthwash test that is covered by most insurance carriers. Both maternal and paternal family history is important since BRCA mutations can be inherited from either your mother or your father. Additional criteria for BRCA gene testing can be found at www.cancer.gov. Only after understanding your BRCA-mutation status can you rationally determine if Jolie’s decision is the right one for you.

For BRCA mutations carriers who elect preventive double mastectomy, surgeons specializing in the treatment of breast cancer can offer a range of breast reconstruction options that remove the insides of the breast while preserving the nipple and breast skin. This preserves and sometimes even improves the outward appearance of the breast thought the resulting breast usually lacks normal sensation. Preventive double mastectomy procedure can be performed through a small 2-3 inch incision on the front of the breast or through a small incision that can be hidden behind the breast. These options are also available to selected non-BRCA mutation carriers who desire double mastectomy for treatment of cancer.

Publically confronting a diagnosis of a BRCA mutation takes personal courage and the kind of steely determination that epitomizes Jolie’s many starring movies roles. In her current real life starring role, Jolie is not only inspiring, she also provides a tremendous gift to women and men who until now may have been unaware of this condition.

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Dennis R. Holmes, M.D., F.A.C.S. is a Breast Surgeon and Medical Director of the Los Angeles Center for Women’s Health. For more information about Hereditary Breast and Ovarian Cancer Testing, Breast Cancer Risk Assessment, or Preventive Double Mastectomy, contact the Los Angeles Center for Women’s Health at (213) 742-6400.