Jolie op stirs debate
Angelina Jolie’s double mastectomy has raised questions regarding the necessity of genetic analysis and preventive surgery
Angelina Jolie’s double mastectomy has raised questions regarding the necessity of genetic analysis and preventive surgery.
ince Hollywood megastar Angelina Jolie announced she underwent a double mastectomy after discovering she has a genetic mutation that put her at an extremely high risk of developing breast and ovarian cancer, women around the world have asked themselves whether they should do the same.
This question is not an easy one to answer. Aside from the physical and health aspects, there are also psychological and emotional considerations to take into account.
According to surgeon Dr Pongnares Purasiri, preventive double mastectomies — also known as prophylactic mastectomies — have been carried out by specialists around the world during the past three decades. Jolie lost her mother Marcheline Bertrand to ovarian cancer in 2007 when Bertrand was only 56. And Jolie’s gene testing found a genetic mutation that, in her case, increased the chance of developing breast cancer to 87% and ovarian cancer to 50%. The actress thus decided to have the double mastectomy to lower her risk of cancer.
‘‘Prophylactic double mastectomies, like the one Jolie has undergone, are not a new phenomenon,’’ said Dr Pongnares, adding that Jolie underwent a mastectomy involving the surgical removal of only the breast tissue, not the nipple.
‘‘After the mastectomy, breast reconstruction with an implant has been performed.’’
Everyone carries the BRCA1 and BRCA2 genes, which suppress the development of tumours. Problems arise when BRCA1 and BRCA2 mutate, which is suggestive of abnormalities, such as their tumour-suppressing functions being disabled, increasing the chance of developing cancerous cells.
‘‘Genetic mutation of BRCA1 and BRCA2 will increase the odds of developing breast and ovarian cancer,’’ explained Dr Pongnares, who is also a breast cancer specialist. ‘‘If [a mutation of] either of the genes is detected, it increases the chance of developing breast and ovarian cancer to approximately 60 to 65%. If both genes are found, chances rise to 80%.’’
But BRCA1 and BRCA2 are not accountable for the majority of breast and ovarian cancer cases. On the contrary, just like some other types of malignancy, the cause of breast and ovarian cancers is not yet known. While up to 90% of breast and ovarian cancer cases are caused by non gene-related factors such as age-related cell abnormalities or the environment, only a minority of patients suffering breast and ovarian cancer have BRCA genes to blame.
Family history plays a significant role in the development of breast and ovarian cancer, said Dr Pongnares. But again, it does not necessarily mean that all breast and ovarian cancer patients will pass the mutated BRCA1 and BRCA2 genes to their children. If a mother, for instance, has breast cancer and is found to carry a mutated gene, the likelihood that the gene will be passed to the kids is only 10%.
Gene testing is a method to check whether there is a genetic mutation of BRCA1 and BRCA2 inside the body. In Thailand, the medical procedure is not available, still it is not impossible to determine. Blood samples can be sent for analysis in other countries such as Hong Kong. The procedure takes approximately three to four weeks at a price of more than 30,000 baht.
Dr Pongnares underlined the fact that such a diagnostic method is not recommended for everyone.
‘‘Honestly, price is not the only thing that should be taken into account,’’ he said. ‘‘The consequence is in fact what people should be most worried about. Imagine if your gene testing shows positive results and you now know you will [probably] suffer cancer at some point in life. What would you do? How would you react? It will effect not just your family life, but also your career and social life.
‘‘A lot of questions will follow, such as whether or not you and your family will be able to accept the fact that you are facing cancer, what you would do if it happens during career success, how you would deal with people around you, and so forth. These are the emotional and psychological costs of gene testing and you need to gauge whether it’s worth knowing the truth.’’
Because the tests can be heartbreaking, doctor-patient counselling is regarded as an essential tool both before and after testing. That way the patient can decide whether gene testing is really necessary and it will help them to cope with the outcomes if the test comes back positive.
‘‘Prior to gene testing, you need to be evaluated for whether you are at a high risk of developing breast or ovarian cancer,’’ said Dr Pongnares.
‘‘If you have family members who suffered breast or ovarian cancer at the age of no more than 40 years old, you might probably need cancer-gene screening. But then again, family members of your lineal ascent — your mum, for instance — who suffered cancer need to be screened for mutated BRCA genes first. If they are found to have the [mutated] gene, then you can consider getting tested. If not, then gene testing is not necessary.’’
If the test does detect mutated BRCA genes, counselling is again necessary to figure out the most appropriate way to cope with the risks.
Firstly, said the breast cancer specialist, those who are found to carry mutated BRCA1 and/or BRCA2 will be closely monitored. A mammogram and an ultrasound to check the abdomen and the ovaries, must be carried out regularly as these procedures can help detect cancerous cells in their early stages.
Secondly, mutated BRCA carriers will be prescribed Tamoxifen, which can help prevent the development of cancerous cells by 60%.
Thirdly, patients may choose to have the affected body parts removed.
‘‘The choice depends on each individual,’’ commented Dr Pongnares. ‘‘If they decide to have a mastectomy or an oophorectomy [removal of the ovaries], they need to think carefully about the consequences.
‘‘A mastectomy might affect selfconfidence. Without breasts, they might be worried about what their husbands and others think of them. If they are to have an oophorectomy, they cannot get pregnant. Yet if they have their breasts removed, they can still get pregnant, but they cannot breastfeed. These are among very important outcomes they must think about very thoroughly before making a decision.’’
For Jolie, her pre-emptive double mastectomy could be considered smart, given she has children as well as tremendous support from people around her. But for others, attentive counselling before and after BRCA gene testing is key to helping them with such a difficult choice.
‘‘Undergoing the gene testing is easy,’’ said the surgeon. ‘‘Blood samples are collected and you just pay the money. But coping with the consequences is the most difficult part. In case of negative results, end of story.
‘‘But if the results are positive, will you be able to cope? What are the next steps? And will you be able to cope with the consequences of the next steps?
‘‘These are issues that must be agreed upon, because [the outcomes can have] not just physical, but also emotional, psychological and social costs.’’