Hollywood megastar Angelina Jolie two weeks ago announced that she had her ovaries and fallopian tubes removed over fears of a hereditary form of cancer. This is the second time she has told the world of her risk of the disease, following her announcement two years ago that she had undergone a double mastectomy.
Once again, Jolie's decision was received with mixed feelings. Hers was a bold move for many; others commented that she was irresponsible to have triggered excessive worry among females worldwide.
Gynaecologist Dr Wisit Supakarapongkul applauded Jolie's decision. He said the removal of ovaries — an oophorectomy — and fallopian tubes in her case is an effective way to prevent cancer if the risk is extremely high.
"Her decision was very brave and determined. For a woman to make up her mind to have such an important organ as an ovary removed, the decision is never easy. It takes so much time to think this through. Jolie did it at will. She was not forced to do so by her doctor. This is full of courage," said Wisit, the president of the Thai Gynecologic Cancer Society.
Angelina Jolie. Photo: AFP
Two years ago, before the 39-year-old American actress had her breasts removed, she was diagnosed as carrying a mutated BRCA1 gene, which put her at an extremely high risk of developing breast and ovarian cancer. Jolie's mother, aunt and grandmother were also suffered and subsequently died from breast and ovarian cancer when they were under 60 years old.
Cancer, of course, is not 100% hereditary. But according to Wisit, for breast and ovarian cancer in particular, if the mutation of BRCA1 or BRCA2 — genes which suppress the development of tumours — are found in a patient, the risk of developing these types of cancer becomes significantly higher.
"Of the female population, 10% are likely to fall prey to breast cancer, while 5-10% to ovarian cancer. But if the mutated BRCA1 or 2 is detected, the chances of a person eventually suffering from breast cancer is 50% higher. For cancer of the ovaries, the likelihood increases by 20-40%," he added.
For those with BRCA1 or BRCA2, removing the potentially affected organs can be considered a preventive procedure. But neither mastectomies and oophorectomies a guarantee that a person will be totally safe from cancer.
"If you have only one ovary removed, for instance, cancer might develop in the remaining ovary. If you only have your ovaries removed and keep the fallopian tubes, it is still likely that cancer will attack the fallopian tubes. Such a genetic mutation can also cause peritoneal cancer or cancer that affects the thin layer that lines the inside wall of the abdomen," Wisit said, adding that BRCA1 and BRCA2 mutations can also occur in men, leading to cancer of the breasts, prostate and pancreas. Breast cancer in men, while rare, is greater in terms of severity than in women.
"Although ovarian and breast cancers are not 100% preventable by means of oophorectomy and mastectomy, it is medically proven that such preventive surgeries can reduce death rate, especially when compared to those who do nothing," Wisit said. "According to a medical study, the removal of ovaries and fallopian tubes can lower the risk of ovarian cancer by 80%."
Gene testing to detect the mutation of BRCA1 and BRCA2 is not recommended for everyone for several reasons. First, the cost is quite high — around 30,000 baht. Also BRCA1 and BRCA2 mutations are responsible for only a minority of cancer cases — approximately 10%. In Thailand, the gene testing is currently only available at Chulalongkorn University Hospital and Siriraj Hospital. At present, the screening method, which requires collaboration from specialists on gynaecological cancer and genetics, is mostly carried out for research purposes.
Wisit said gene testing would be recommended for those with an apparently high risk of breast and ovarian cancer. If a patient, for example, has a family member who has mutated BRCA1 or BRCA2 genes; has a mother or grandmother who has had breast cancer before age 45; has one or more family members who have had cancer of both breasts; has a family history of either breast and ovarian cancer; or has a male family member with breast, prostate or pancreatic cancer, the family members must first themselves have the gene testing. If the mutated BRCA1 and/or BRCA2 is spotted, the patient might consider having the gene testing as well."
If the mutation is detected, then the choice is up to the patients — opt for removal of the organs or, if not, receive regular follow-up medical examinations.
"Chemo can be an alternative if patient decides not want to have the preventive surgery," Wisit said. "But then again, this approach is not 100% effective. Contraceptive pills are said to be able to prevent ovarian cancer, but they are also believed to possibly lead to breast cancer."
Jolie's decision might cause paranoia, sparking unnecessary fears. But speaking from a medical point of view, Wisit believes that Jolie's decision has raised awareness regarding cancer.
"What Jolie did at least makes people know that certain diseases can be genetic, but that they are screenable, preventable and treatable," he said. "And I think this is what everybody should be aware of in case it happens to you or someone in your family. And when the time comes, you will be ready to make an appropriate decision."
