The “Angelina effect” is no doubt, incredibly powerful. This of course refers to Angelina Jolie’s ability to significantly guide the decision making of millions of Americans, simply through the expression of her own personal opinion—including her decision to undergo a preventative double mastectomy, a surgery designed to remove all traces of breast tissue.
According to Jolie’s New York Times op-ed last year, an extensive family history of breast and ovarian cancer, combined with the presence of the BRCA1 gene in a genetic test, helped her make the decision. Her choice to undergo this serious surgery and then make her personal experience public drew both praise and concern. I feel that she accomplished at least one very important milestone: She forced Americans to start thinking critically about their health.
A high profile celebrity demonstrating laudable courage and openness highlighted the intensely personal struggles faced by the 235,030 Americans diagnosed with breast cancer and the 40,030 who will pass away from the disease this year. However, critics underlined concerns about the effects of such knowledge and whether it would result in the overutilization of genetic testing and radical surgery.
A study published today in JAMA Surgery from the University of Michigan Comprehensive Cancer Center provides a foundation for these concerns. The study aimed to help elucidate the common motivations for pursuing a double mastectomy. Nearly 1,500 women, who were treated for breast cancer and did not demonstrate any evidence of recurrence, participated in this study.
The authors found that 18 percent of patients considered the possibility of a double mastectomy, while 8 percent went on to have the surgery. The study notes that nearly 3 out of every 4 women in the study population reported significant concern about cancer recurrence and that women who underwent the double mastectomy were even more likely to express worry over recurrence. Interestingly, the author’s reported that roughly 70 percent of women who have been diagnosed with breast cancer and underwent a double mastectomy did not have the genetic factors that would predispose them to cancer in the healthy breast.
The current standard of care for breast cancer varies based on a patient’s history and the nature of the cancer. Surgery, the focus of the study’s authors, is used to surgically excise cancerous tissue. It ranges from a lumpectomy—removing only the tumor and little else—to modified radical mastectomy—in which the whole breast, many lymph nodes, and even some of the underlying chest wall muscle, is removed. Comprehensive multidisciplinary treatment may also include radiation, chemo, hormone, and targeted immune- therapy.
It would seem that a certain population of patients feel that if they have cancer in one breast, it is sure to follow in the other. Fortunately, what we know about breast cancer refutes this claim. The current consensus amongst surgeons, oncologists, and scientists is that removal of the non-affected breast will not mediate the risk of recurrence. The exception is for women possessing a family history significant for breast or ovarian cancer or those with a genetic mutation in BRCA1 or BRCA2. Collectively, this is about 10 percent of all women diagnosed with breast cancer. These women have hereditary breast and ovarian cancer (HBOC) syndrome, in which the majority of cancers are associated with mutations in two genes, BRCA1 and BRCA2.
Women with HBOC hold a lifetime risk of 50-85 percent for breast cancer and 15-40 percent for ovarian cancer. For women without this genetic background, there is no medical reason to believe that the cancer could be lying dormant in the other breast. A cancer diagnosis in one breast does not increase the probability of recurrence in the unaffected breast for women without the aforementioned risk factors.
Breast cancers are classified by where they begin and if they are likely to spread beyond that initial location. A breast mass can be in situ—confined to the area it originated in, or invasive/infiltrating. Roughly 1 in 5 new breast cancer diagnoses will be ductal carcinoma in situ (DCIS), which is considered either non-invasive or pre-invasive. However around 80 percent of breast cancers are Invasive Ductal Carcinomas (IDC).
There are further classifications based on the molecular make-up of the tumor that can be used to guide treatment. A key area of current research focuses on these “molecular subtypes” with the hope of finding a subgroup of cancers that have a genetic code that makes them susceptible to a targeted treatment.
While this study holds implications for health care usage and policy, it most significantly highlights the need for better patient education. A double-mastectomy is a serious operation and calls for a challenging recovery. The point of this study is not to fault anyone who has or has not chosen to undergo the procedure. Rather, it calls on doctors to focus on educating patients and truly understanding a patient’s worries and motivations.
If a double mastectomy provides a certain level of anxiety relief for patients, should surgeons proceed? As we improve detection, treatment, and molecular analysis, cancer patients will face even more complex decisions that are rooted in risk, probability, and quality of life—and it will be the role of the healthcare practitioner to help deconstruct the data into manageable sets of treatment options.