Rabu, 15 Mei 2013

Jolies Disclosure of Preventive Mastectomy Highlights Dilemma

Now four decades later another leading lady the actress Angelina Jolie has focused public attention on breast cancer again but this time with an even bolder message A woman at genetic risk should feel empowered to remove both breasts as a way to prevent the disease. Ms. Jolie revealed on Tuesday that because she carries a cancer causing mutation she has had a double mastectomy.

She s the biggest name of all and I think given her prominence and her visibility not only as a famous person but also a beautiful actress it s going to carry a lot of weight for women said Barron H. Lerner a medical historian and the author of The Breast Cancer Wars.

Breast cancer experts and advocates applauded the manner in which Ms. Jolie explored her options and made informed decisions saying it might influence some women with strong family histories of breast cancer to get genetic tests.

But some doctors also expressed worry that her disclosure could be misinterpreted by other women fueling the trend toward mastectomies that are not medically necessary for many early stage breast cancers. In recent years doctors have reported a virtual epidemic of preventive mastectomies among women who have cancer in one breast and decide to remove the healthy one as well even though they do not have genetic mutations that increase their risk and their odds of a second breast cancer are very low.

Ms. Jolie wrote on the Op Ed page of The New York Times that she had tested positive for a genetic mutation known as BRCA1 which left her with an exceedingly high risk for developing breast and ovarian cancer. Her mother died at 56 after nearly a decade with cancer though Ms. Jolie did not specify which type. After genetic counseling Ms. Jolie opted to have both breasts removed and to undergo reconstructive surgery.

Ms. Jolie 37 who declined to be interviewed for this article was treated at the Pink Lotus Breast Center in Beverly Hills Calif. a clinic opened in 2009 by Dr. Kristi Funk identified on its Web site as a former director of patient education at the breast center at Cedars Sinai Medical Center in Los Angeles.

Her condition is rare. Mutations in BRCA1 and another gene called BRCA2 are estimated to cause only 5 percent to 10 percent of breast cancers and 10 percent to 15 percent of ovarian cancers among white women in the United States. The mutations are found in other racial and ethnic groups as well but it is not known how common they are.

About 30 percent of women who are found to have BRCA mutations choose preventive mastectomies said Dr. Kenneth Offit chief of clinical genetics at Memorial Sloan Kettering Cancer Center in New York. Those who have seen family members die young from the disease are most likely to opt for the surgery.

It s important to make it clear that a BRCA mutation is a special high risk situation said Dr. Monica Morrow chief of the breast service at Sloan Kettering. For women at very high risk preventive mastectomy makes sense but few women fall into that category she said.

For women s health advocates the trend toward double mastectomies in women who do not have mutations is frustrating. Studies in the 1970s and 1980s proved that for many patients lumpectomy was as safe as mastectomy and the findings were seen as a victory for women.

Even so there is increasing demand for mastectomy. Dr. Morrow says that she has often tried to talk patients out of it without success. Some imagine their risk of new or recurring cancer to be far higher than it really is. Others think that their breasts will match up better if both are removed and reconstructed.

Ms. Jolie s decision highlights the painful dilemma facing women with BRCA mutations.

She is a special case and you can completely understand why she did it said Dr. Susan Love the author of a best seller Dr. Susan Love s Breast Book and a breast surgeon. But what I hope that people realize is that we really don t have good prevention for breast cancer. When you have to cut off normal body parts to prevent a disease that s really pretty barbaric when you think about it.

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