What to Know About Angelina's Decision

Preventive mastectomies to reduce breast and ovarian cancer risks are personal choices

/ Author:  / Reviewed by: Robert Carlson, M.D

Mega-star Angelina Jolie announced in a New York Times op-ed that she had both breasts removed. She does not have breast cancer. Ms. Jolie has done this to reduce her risks of developing both breast and ovarian cancer.

Ms. Jolie has also announced her decision to have both ovaries removed in future surgery.

Is this the right decision for other women?

We’ve talked to experts around the country about what’s involved in her decision – one that’s not right for all women.

Angelina lost her mother at the age of 56 after a decade-long battle with ovarian cancer.

Anytime a woman has a close relative with breast or ovarian cancer, it increases her risk of developing the diseases.

To learn more about her risks, Ms. Jolie had genetic testing to see if she had what she called “a faulty gene – BRCA1.”

There are two BRCA genes: BRCA1 and BRCA2.

When not working properly, these genes promote the growth of cancer cells. Women who have changes in one or both of these genes have a greater risk of both breast cancer and ovarian cancer.

How much of an increased risk depends on the woman, and only genetic testing can approximate that risk.

In Ms. Jolie’s case, her doctors told her she had an 87 percent risk of developing breast cancer and a 50 percent chance of being diagnosed with ovarian cancer at some point in her life.

To be proactive and lower her risks, Ms. Jolie decided to have what’s called a “preventive double mastectomy.”

Having both breasts removed reduced her chances of getting breast cancer from 87 percent to under 5 percent. The reduction in her ovarian cancer risks is less clear.

Cancer risks and BRCA mutations

Here's a summary of what altered BRCA genes do to a woman's cancer risks.

  • About 60 percent of women with BRCA mutations will develop breast cancer, compared to 12 percent of women without the mutation.
  • A BRCA mutation increases a woman’s risk of ovarian cancer to 15-40 percent, compared to 1.4 percent among women without the genetic defects.
  • Not every woman with altered BRCA genes will get breast or ovarian cancer.
  • The risk is highest among women who have more than one relative who has had breast and/or ovarian cancer.
  • Women of Ashkenazi (Central and Eastern European) Jewish background are also at particular risk.
  • Overall, BRCA mutations account for 5 to 10 percent of breast cancers in the US – about 15,000 of the 238,340 women who will be diagnosed with breast cancer this year.
  • BRCA defects will account for 10 to 15 percent of ovarian cancers among white women in the US. A total of 22,240 women will receive an ovarian cancer diagnosis this year.

What about genetic testing?

If you have a family history of breast and/or ovarian cancer, you will probably want to talk with your doctor about having genetic testing performed.

It's recommended that you have genetic counseling first, which your physician can arrange for you.

The genetic test involves gathering a blood sample.

The test costs just over several thousand dollars, and most insurance companies cover the fees, according to Myriad Genetics, the company that provides breast cancer genetic testing.

Your physician can explain the test results and what your approximate risks are.

Never a zero risk

Aaron E. Carroll, MD, an associate professor of pediatrics at the Indiana University School of Medicine and the director of the university's Center for Health Policy and Professionalism Research, wrote an op-ed for CNN on Ms. Jolie’s decision.

He points out that, in America, we don’t like risk. “We favor trying to reduce the chance of something bad happening to as close to zero as possible. We also tend to err on the side of doing something rather than nothing. There's nothing inherently wrong with this type of behavior. But we should recognize it,” Dr. Carroll wrote.

He continued, “You can't reduce risk to nothing. Trying to do so will lead to practices none of us would support. After all, someone could make the argument that we should remove all breast tissue from all women because you never know where breast cancer will strike. That's hyperbolic, and no one is suggesting it, but it shows that this is really a personal, and individual decision,” Dr. Carroll said.

The choice

We asked Adam Brufsky, MD, PhD, professor of medicine at the University of Pittsburgh School of Medicine, what his experience is with preventive double mastectomies.

He told us, “It is always the woman's choice. Some women do it, some do not. With the genetics that Ms. Jolie had, the risk reduction of nearly 90 percent is correct, and many women in her situation would do the same.”

Breast cancer specialist, Christopher O. Ruud, MD, with Austin Cancer Centers in Austin, Texas, said, “Preventive double mastectomies do reduce the risk of breast cancer but, this type of surgery is only indicated for women who carry the mutation.”

The risks

A double mastectomy is a major surgery with all the inherent risks that go with that.

If a woman decides to have reconstructive surgery, the surgical complexity becomes even greater.

Without reconstructive surgery, a woman’s appearance will be altered dramatically.

The costs of these surgeries are high and not all insurance companies will pay for preventive procedures.

A personal decision

When we asked Dr. Brufsky how he counsels his patients, he told us, “I leave the decision up to them after I have discussed the risks and benefits.”

The take away message here is that just because a major movie star decided to take the ultimate step in reducing her cancer risks doesn’t mean that this is the right course for all women.

If you have a family history of breast cancer, ovarian cancer or any other cancer, speak to your doctor about the next best steps for you – as an individual.

Gather as much information as you wish to gather, that you can afford or that your insurance carrier will pay for, then take your own counsel about what’s best for you.

"I wanted to write this to tell other women that the decision to have a mastectomy was not easy. But it is one I am very happy that I made...I can tell my children that they don’t need to fear they will lose me to breast cancer," Ms. Jolie wrote.

Review Date: 
May 13, 2013