Monday, May 20, 2013

Angelina Jolie’s Breast Surgery….

Angelina Jolie’s Breast Surgery….

By now everyone- on both sides of the fence- has had their say on the Angelina Jolie preventive breast removal. If you are one of the rare species of mankind who has missed out on hearing about it (or reading about it), the news last week was that Angelina Jolie has had bilateral radical mastectomy which is trade-speak for surgical removal of both breasts to prevent cancer. This is a rarely used technique of cancer prevention, which is sometimes mentioned to patients as one more option but very rarely as a serious option.

The basic requisite for this surgery is that the patients must have confirmed genetic markers for breast cancer- brca1 & brca2 genes - which indicate that the person has a very high chance of getting breast cancer and there must also be documented history that the patients mother or grandmother must have had breast cancer in the past. When both conditions are present- a positive family history and a positive genetic presence of disease- the patient is offered the option of removing the breast tissue before cancer develops.

Not many patients choose to do so as they fancy their chances and wait to see if they do indeed develop the disease or not, for a chance is just that- a probability- there is no certainty that each and every patient will develop that disease. They may or may not. So most patients prefer the option of careful vigilance and frequent testing for presence of suspicious lumps and then decide to undergo surgery if necessary.

But a few rare patients like Jolie prefer to remove their fear once and for all by total removal of all breast tissue to reduce their chance of cancer. Because once past the childbearing and breast feeding age the breast serves only a cosmetic purpose and not a physiological purpose. Loss of breast is disfiguring but it’s not life threatening, so it’s every individual’s choice. But preventive removal of body parts is so extreme a concept that even doctors hesitate to advocate this treatment as a  routine procedure and hedge their bets by offering other choices first - prescribing drugs like Tamoxifen which taken regularly reduces the chances of developing breast cancer.

The one thing which complicates breast cancer compared to other cancers is the presence of silent (distant) secondaries- clumps of cancer cells which move away from the breast into other parts of the body where they develop into further cancers. This needs chemotherapy and irradiation and even then we are not sure that the whole thing has gone away, complicating the assurance given to the patient that they can henceforth lead a normal life from that point on. So all in all, this is pretty confused issue where the blind leads the blind.

Angelina Jolie has celebrity status and hence whatever she says has high recall value among the public all over the world. By publicly talking about her surgical breast removal she makes one wonder how many others will now follow her example?  And if it’s at all necessary? Or even possible for every single BRCA carrier to undergo this preventive breast removal? 

Although the statistics which Angelina Jolie quoted in her speech about breast cancer genes brca and cancer possibilities is frightening at first glance- like 12% of all patients have this gene and 80% of those with the gene develop cancer, let me state that these statistics are based on association studies. For those who are not familiar with association studies- it means that in a given patient - these two separate factors are present and there may be a possibility of them being linked together.

Let’s take a local example. On a Sunday morning at 7AM there is a big crowd of people at the Marina Beach (famous beach in Madras city). If someone did an association study based on the above fact they can extrapolate the data to say

1) Sunday mornings are crowded at marina beach.

2) A big crowd worships the sun god at marina beach every Sunday at 7Am

3) The sun god makes an appearance at marina beach at exactly 7am every Sunday to meet his devotees.

4) Only if there is a big crowd on the marina beach at 7 am will the sun rise on Sundays.

The first point above is the observational data, the others are just assumptions, some more fanciful than the rest. Most observational studies are just like this; you take two facts and try to link them using your imagination and probabilities. Some may turn out to be true; some may be just random association and some you know to be true but can’t think up a single valid reason on why it should be so.  Hence to give too much credence to association studies is not very wise.

 So what if you are still worried about the possibility of getting it and still want to test yourself on the off chance of it being true. Before you pressurize your doctor into ordering this test for you, you should know that one important factor about this gene test which is not much talked about is that a single biotech company in the USA has patented this Brca gene and hence they are exclusive manufacturers of the gene test. Because of that monopoly the test costs three thousand (or $3000) dollars in the USA and translated to Indian money it would work out to one and a half lakhs (or Rs.1,50,000) rupees in hard currency. For that amount all you get is knowledge about the presence or absence of the BRCA gene in your body cells. And sleepless nights. For with a positive result- if the gene is present- you might get cancer. Then again, if the gene is present- you might not get cancer. You never know, either way.

Don’t get me wrong, I am not advising against taking this test. All I am doing is simply stating that one test is not conclusive evidence that you will definitely end up getting cancer. There are lots of factors, many of them still unknown, involved in cancer. Read this- my earlier post about the cancer scare. But the cancer crusaders are definitely doing a disservice by creating too much hype and over-scaring people. A little commonsense goes a long way when you are struggling with the decision to believe all the hype or not.

So to come back to Angelina Jolie's decision, all I can say is- it’s her body, she has every right to it- to do whatever she wants- to get a tattoo, to get body piercings or to remove a breast or two. In her long career of wacky decisions this is just one more. Let’s not read more into this than just that. Let’s not turn her into a crusader of cancer health and insist that others follow her example. What’s good for the goose, errr, in this case, for Angelina Jolie, may not be good for everyone else. Women- make your own decisions please.


  1. A well-balanced and informative post Ganesh. I think Jolie was brave but as you've said , it is not a one-size-fits-all solution.

    Another point to note is that - however silly or frivolous it might be - most women consider their breasts as symbols of femininity; voluntarily having them cut off simply based on a suspicion does affect a woman's sense of body image. While Jolie could afford to get implants, not sure if the average woman would be able to afford it.

    1. Thanks for stopping by Anne..and yes i agree that a lot of emotional turmoil is involved when it comes to breast surgery but all i am saying is that if it becomes absolutely necessary then there are no second thoughts involved, i would advise my patients to go for it. but, in this instance there is no immediate necessity for it. this was a choice made out of panic and that the reason i wonder whether angie got the right medical advice before she decided this course of action.

  2. Seems strange and brave at the same time to have done something this extreme... but she has seen her mother and grandmother suffer and she did not want to go down that same path. It may motivate others to get tested, but apparently only the wealthy ones can afford it in the first place. So yeah, calling her a pioneer may be a little far fetched...

    1. i can understand the thought process behind her decision Karen..even though i feel that she was a bit premature, thats why i believe she might not have got the correct medical advice before opting for this course of action..anyway, this is a one-off extreme act and not to be recommended routinely

  3. Seems strange and brave at the same time to have done something this extreme... but she has seen her mother and grandmother suffer and she did not want to go down that same path. It may motivate others to get tested, but apparently only the wealthy ones can afford it in the first place. So yeah, calling her a pioneer may be a little far fetched...