On March 24, 2015, Jolie published a public diary in the New York Times: “I told myself to be calm and strong, that I had no reason to believe I wouldn’t live to see my son grow up and have grandchildren. …… Last week, I had surgery, a laparoscopic bilateral ovarian oophorectomy. There was a benign tumor on one ovary, but no signs of cancer.” Once again, the medical community at home and abroad is in an uproar!
Some people said that she had the courage to break her wrist and save her life, but for more ordinary women there is only one question: did she really have to cut herself so hard, wouldn’t it be more appropriate to follow a strict follow-up to “cut her nails”?
Should women who are unfortunate enough to find out that they or a family member has a BRCA1 or BRCA2 mutation do the same as Jolie and go on to have their ovaries removed after the mastectomy? Personally, I think it’s a matter of personal choice and probability. But before making a decision, at least some basic facts should be known as follows.
People at high risk should be tested for BRCA1/2
What is a high-risk group? It means that if one of the following is met in the family (especially in the direct blood line).
1. Breast cancer younger than 50 years old;
2. One person has breast cancer in both breasts;
3. One person has breast cancer and ovarian cancer at the same time;
4. Multiple breast or ovarian cancers;
5. Male breast cancer.
The presence of one relative does not indicate a high risk. The most scientific way to determine this is to do genetic testing on the patient and find out that they do have a mutation in the BRCA1/2 gene, and then their close relatives are determined to be at high risk.
Does testing for BRCA1/2 need to start at a young age?
The answer is no! Even if this child has a family history of being in a high-risk group, ASCO does not recommend it. The reasons are based on the following.
1. There is no specific way to prevent the occurrence of cancer even if the mutation is known, which adds to the psychological stress;
BRCA1/2-related cancers have a high incidence after the age of 35, so even if you are concerned about family history, you should wait until you are an adult and talk to your doctor before deciding whether you need to have the gene tested and whether you need to do any follow-up preventive measures after the test.
Benefits of Preventive Excision
Studies have demonstrated that removal of the breast can almost completely prevent cancer near the breast if it carries the BRCA1/2 mutation. Removal of the ovaries not only significantly reduces the incidence of cancer near the ovaries (by 80-90%), but also reduces the incidence of breast cancer (by 50%) because estrogen produced by the ovaries promotes breast cancer, and after removal of the ovaries, estrogen production is greatly reduced and the incidence of breast cancer is consequently reduced. Therefore, there is no doubt about the effectiveness of this type of “prophylactic surgery” in controlling cancer (Associationof risk reducing surgery in BRCA1 or BRCA2 mutation carriers with cancer riskand mortality. JAMA. 2010 Sep 1;304(9):967-75.).
The downside of prophylactic resection
Surgery carries risks, and you are advised to choose carefully. In addition, the disadvantages of mastectomy are mainly aesthetic and psychological changes. Removal of the ovaries, on the other hand, has very direct physiological effects. The ovaries are the site of egg and estrogen production, and the most obvious effects of removing the ovaries include
1. loss of the ability to conceive naturally;
2. early onset of menopause with numerous sex-related problems;
3. the development of significant osteoporosis;
4. increased probability of various cardiovascular diseases.
Are there alternative options?
Removal of the breast and ovaries is not 100% preventable because people with BRCA1/2 mutations have a higher chance of developing other malignancies such as pancreatic cancer even after removal of the breast and ovaries. Because excision does not prevent 100% of the occurrence and carries significant long-term side effects, many people choose to forgo this procedure. Some other options include.
1. Routine screening. Annual mammograms, for example, can help detect breast cancer in its early stages and reduce the risk. For ovarian cancer, which is a “silent killer” (late detection – silent, killer – mortality rate is the highest among gynecological tumors), there is no particularly sensitive early detection method. Tumor markers, including CA-125, cannot reliably detect early-stage ovarian cancer.
2. Preventive medicine. Studies have shown that long-term use of oral contraceptives can reduce the incidence of ovarian cancer by 40% to 50% in women with BRCA1/2 mutations
(Reproductiverisk factors for ovarian cancer in carriers of BRCA1 or BRCA2 mutations: acase-control study. Lancet Oncol. 2007 Jan;8(1):26-34.) In addition taking anti-estrogen drugs such as tamoxifen has the potential to reduce the incidence of breast cancer.
3. therapeutic agents. the PARP inhibitor Olaparib, specifically used for the treatment of ovarian cancer with BRCA mutations. Unfortunately, this type of drug is not yet available in China, and China is expected to be at least 2 to 3 years late.
Did Jolie make the right choice?
Simply put, Julie chose the former between the risk of surgery and post-operative side effects and the 50% or so chance of ovarian cancer by age 70. In fact, different people must have different decisions when faced with this kind of multiple choice question. If the probability is 5% or 90%, the choice may be much easier. 50% is indeed a threshold of choice, and a correct choice is a door, and a wrong choice is a hurdle!
This is a choice without the right answer, your own body makes its own decisions. After knowing the science and making a choice, go your own way and let the answer to the dilemma of “cutting” and “nail clipping” fly in the wind!