In an op-ed for the New York Times today, Angelina Jolie Pitt announced that she had surgery to remove her ovaries and fallopian tubes to reduce her risk for cancer. Two years ago she wrote a similar piece for the Times about her decision to have a double mastectomy after testing positive for a mutation in the BRCA1 gene that greatly increased her risk for breast and ovarian cancer. The announcement has sparked renewed conversation in the medical world and media about the decision-making process that leads to preventive surgeries for women at risk for breast and ovarian cancer.
Science Life asked Iris Romero, MD, MS, Associate Professor of Obstetrics/Gynecology, Olufunmilayo I. Olopade, MD, FACP, Director of the Center for Clinical Cancer Genetics, and Diane Yamada, MD, Chief of the Section of Gynecologic Oncology at the University of Chicago Medicine, to respond with their thoughts on Jolie Pitt’s difficult decision:
The decision to prophylactically remove one’s ovaries is deeply personal and complex. Through the years, Ms. Jolie Pitt has generously shared with the public her experiences as a BRCA1 carrier. As a BRCA1 mutation carrier, Ms. Jolie Pitt had a significantly elevated risk of both breast and ovarian cancer. Recognition of her family history and the need for genetic testing was critical in the pro-active approach Ms. Jolie Pitt took in reducing her risk for cancer. She and her health care providers should be congratulated for acknowledging the importance of this first step.
After finding out her BRCA status she underwent preventive removal of her breasts . This final surgery to remove her tubes and ovaries, as she mentions in her article, is a straightforward procedure but has the consequence of inducing menopause. Therein lies the complexity of the decision as the patient will no longer be able to conceive naturally and will likely have menopausal symptoms. In general, it is recommended that women delay the surgery until they have completed childbearing, however, treatment options do exist to bank embryos and undergo in vitro fertilization after removal of the ovaries if needed. The menopausal symptoms are an important consideration and can be addressed by a variety of approaches including the one described in the article using an estrogen patch and a progesterone IUD. Given the induction of menopause from the surgery, the timing of when to remove the tubes and ovaries must be considered carefully and tailored to the individual’s family history. Ms. Jolie Pitt had her ovaries and tubes removed when she was 39 years old; her mother was diagnosed with ovarian cancer at age 49. The type of surgery also needs to be individualized. All BRCA mutation carriers should have both tubes and ovaries removed. Most patients will not need to have their uterus removed, which is a more complex surgery. Ms. Jolie Pitt mentions “there are options for women to remove their fallopian tubes but keep their ovaries…”. There is early evidence that some ovarian cancers may begin in the fallopian tubes, but currently there is no clinical testing indicating that removal of only the tubes is sufficient for preventing ovarian cancer.
Until the time of preventive surgery patients can reduce the risk of ovarian cancer by using oral contraception. Several epidemiologic studies indicate that using oral contraceptives reduces the risk of ovarian cancer by up to 50%. Prior to removal of the tubes and ovaries, the patient and her physician may also consider screening for ovarian cancer. As Ms. Jolie Pitt describes she was having pelvic ultrasounds and a blood test called CA 125. Currently these are the only screening tools available for ovarian cancer, however, they have significant limitations for detecting early cancer in addition to causing harm by generating false positive results. A false positive test occurs when the results indicate that cancer is present but at the time of surgery no cancer is found. False positive results lead to anxiety and unnecessary additional testing. BRCA mutation carriers should be informed of the limitations of ovarian cancer screening and screening should not be performed on patients that do not have a family history of ovarian cancer. Ms. Jolie Pitt appears to have optimized the full range of ovarian cancer prevention options. Importantly, by sharing her journey in public forums she is empowering other BRCA mutation carriers to do the same.
Olopade also spoke to CNN today about Jolie Pitt’s announcement:
“I can’t emphasize enough how important this is … What she’s done is really important to save her life, because there’s no way to detect ovarian cancer.”
And in the the Chicago Tribune, she spoke about the impact of genetic testing on cancer prevention:
“We have studied this gene for more than two decades, and we know that celebrities like Angelina Jolie have helped people realize that knowledge is power … The beauty is that women have choices — and those choices are being made by women not just in this country, but all over the world.”
Yamada spoke to the Guardian about how the star’s openness about her decision has increased awareness:
“There was a huge spike in awareness after her original piece … We, and a number of other organizations, try all the time to increase people’s awareness of the ovarian cancer risk because a lot of physicians don’t necessarily recognize patients’ family history and don’t highlight the fact that a lot of patients should get genetic testing done, or genetic counseling done.”
The Society for Gynecologic Oncology, the leading medical specialty society for the comprehensive management of gynecologic cancers, also issued a position statement on genetic testing for gynecologic cancer.