Oncologist, geneticist, and psychotherapist about the removal of the breast and ovaries
Angelina Jolie published a column in the New York Times, where he spoke about his fight against the threat of cancer. Following a double mastectomy, that is, the removal of both Breasts, Jolie had surgery to remove the ovaries and fallopian tubes. She spoke about the process of making this difficult decision and urged women to be attentive to their health and understand that timely detection of the disease or its adequate prevention increases the chances of a long and happy life. The column has aroused strong repercussions in social networks, including reviews of a negative character — Jolie accused of alarmism and in the promotion of inappropriate methods of treatment.
A large number of comments condemning the actress confirmed that with all the progress in technology and diagnosis, many still prefer not to know or think about the potential problem until the thunder breaks, and awareness of Russians about the prevention of cancer and how to treat them is far from ideal. Another reason for such a negative reaction to the removal of the reproductive system at such an age lies in the stigmatization of such operations and women who have undergone them — in a child-centered society, “cut off everything” automatically means “stop being a woman” and “lose value” in the eyes of men. We asked the oncologist surgeon who took part in the treatment of angelina Jolie’s mother, as well as the geneticist and psychotherapist to comment on this situation and talk about new technologies and current methods of prevention and treatment of female cancer, which should be known to all.
Every eighth woman in the world has breast cancer. In Russia, the situation is somewhat worse, because women are often more dismissive of early diagnosis and doctors do not know it well enough, for example, often replace mammography with ultrasound or even a simple examination of the mammary glands. In breast cancer, as with any other type of cancer, it is very important to diagnose it as soon as possible, then more chances to cure it. Survival depends on the stage at which the disease was detected. But there are, of course, many other nuances. For example, some tumors are hormone-sensitive, and in such cases the prognosis is better. There are a number of tumors that do not have receptors for hormones, they are more often more aggressive, worse respond to chemotherapy and, accordingly, are not treated with hormonal agents.
Fortunately, there is an early diagnosis of breast cancer-for most diseases it is not. If you follow the recommendations of doctors and after 40 years to undergo mammography once a year, the probability of not dying from breast cancer increases significantly. Women over 30 years of age need to visit a mammologist and do breast ultrasound every three years, and this is provided that they have no special problems with the mammary glands, there were no seals, tumors and patients do not have a genetic predisposition to cancer, like the same Angelina Jolie.
The genetic risk of breast or ovarian cancer comes from the family history of cancer. If your mother, grandmother or aunt at a young age suffered premenopausal cancer (that is, breast or ovarian cancer — they are often combined into one syndrome), you are at risk. The chance to get cancer in this case increases tremendously. Of course, there are sporadic cases, but there are certain syndromes, as in the case of Angelina Jolie, — BRCA1 and BRCA2. In carriers of the mutation of the first type, the risk of getting breast cancer at a particular age is 85%, that is, in fact, every first carrier.
Genetic tests reveal if there is a mutation. About the risks conclusions are already made by doctors, they look at the type of mutation and then everything is known. It is more important to the gynecologist or breast correctly collected anamnesis. I always ask patients who come with conditional thrush or cervical dysplasia, what their relatives were sick with, what degree of kinship and at what age they suffered from the disease. When a woman says: “my aunt died of breast cancer at the age of 45, my grandmother had ovarian cancer and my mother had a tumor, but it seems benign and it was cut out” — the doctor must understand that the patient should be checked for the carriage of these mutations. We usually test women whose relatives have had ovarian or breast cancer at a young age; those who have already been diagnosed with breast or ovarian cancer before the age of 50; and women who undergo multiple biopsies about breast tumors, seemingly benign, but it is not clear. It so happens that a woman has a very convincing family history of certain oncological diseases, but for some reason, mutations are not detected in her. In such cases, we sequence the whole gene BRCA1 and BRCA2 and see if there is a mutation in some atypical loci (places), and often find it there.
It makes no sense to undergo genetic tests routinely. Moreover, if parents have a mutation, we recommend that they do not test their children before they reach 20-25 years of age. The risks of cancer begin to grow in 30-35, so that, in addition to anxiety, parents, this information will not add anything. After 20 years, the results we warn: your risk of cancer up to 35 years is low enough and you have a chance to realize the reproductive function to the extent that you want. However, the harm from such tests, except that financial.
One in four carriers of the first type of mutation dies from ovarian cancer. Such sad statistics.
I worked in the USA for nine years and took part in the treatment of Angelina Jolie’s mother when she had a relapse of ovarian cancer. She was 54 years old at the time and died at 56 from breast cancer. She was identified two mutations-and the first and second types. In their family, indeed, almost all women suffer from breast or ovarian cancer. To all my patients who are found to have a mutation, I explain for a long time what the risks are. Fortunately, in cases of breast cancer, we have protocols of intensive screening: we begin to monitor the status of carriers of mutation much earlier than usual, up to 25 years, every six months alternate mammography and breast MRI, mammologist conducts examinations. If you comply with these conditions, it is possible to delay the removal of the breast.
With ovaries, everything is much worse: carriers of the mutation of the first type are likely to get ovarian cancer 54 % – that is, every second woman. Unfortunately, 80 % of those affected find out about this, when the cancer is already at stage three. At this stage, the survival rate even with the most aggressive treatment is 35% at best. That is, every fourth carrier of the mutation of the first type dies from ovarian cancer. Such sad statistics. For this reason, knowing that the risk increases at the age of 35 years, I recommend to all my patients — carriers of gene mutations BRCA1 and BRCA2 preventive removal of ovaries and fallopian tubes by laparoscopic.
This preventive operation significantly reduces the risk of cancer, but does not reduce it to zero. In 7-10% of cases, when removing the ovaries, we already find a microscopic tumor. This means that we are late with prevention and cancer has already begun to develop. There is another subtype of ovarian cancer called primary peritoneal carcinoma — it is actually the same ovarian cancer, but it does not start on the ovaries themselves, and on the surfaces of the peritoneum. It can occur even after removal of ovaries and fallopian tubes in carriers of mutations. It’s less likely, but it can’t be ruled out. We always warn women that they can get ovarian cancer, even if the ovaries are gone, no matter how paradoxical it may sound.
Patients react to preventive operations in different ways. Those who have died in front of cancer relatives themselves sometimes come and ask to remove the ovaries and fallopian tubes. Another thing is when a woman of forty years old gets breast cancer and we detect her mutation — at this age it is more difficult to say goodbye to the ovaries, especially if the patient does not have children yet. Then we start the race: ask the woman to get pregnant and give birth as quickly as possible and then remove the ovaries. The problem with 40-year-old women is that they often cannot get pregnant quickly — the ovarian reserve is usually not very good by this age. The reproductologist comes to the rescue, he conducts IVF, receives and freezes eggs or embryos and only then we remove the ovaries, and the woman can endure this pregnancy without ovaries.
Physically, the surgery to remove the ovaries is easy for the patient. The procedure takes 30-40 minutes. A woman comes to the clinic on the day of surgery a couple of hours before and the next day goes home, if necessary — takes sick leave for 3-4 days. Psychologically, this is more difficult to cope with. After removal of the mammary glands and ovaries, women begin to perceive themselves differently, it changes them psychologically. Although it all depends on the person. Many patients after mastectomy immediately put implants and live as before, enjoying a low risk of getting breast cancer. With ovaries there is no option to put implants. Removing the ovaries, for example in 35 years, a woman enters menopause. She begins a climax, and it adds a number of physical and psychological problems. Theoretically, they can be solved or facilitated by hormone replacement therapy (HRT), but there are difficulties, because with prolonged use of HRT itself can provoke the development of breast cancer. Therefore, many women refuse hormonal therapy and take some form of non-hormonal drugs that help fight tides, mood swings and everything else. As for sexual life, patients with removed ovaries complain of vaginal dryness and sometimes a decrease in libido, but the dependence of the latter on the presence/absence of ovaries has not yet been proven.
Angelina Jolie was tested for gene mutation, the risk of the disease was assessed based on its pedigree. I think she did tests on a number of other indicators. Most likely, and mastectomy, the actress decided not only on the basis of genetic test — of course, there is the need for an integrated approach. A few years later, Jolie underwent surgery to remove the ovaries. This step is quite understandable, because women in natural menopause risk of ovarian cancer increases. For her, it was a justified preventive measure, taking into account the mutation of the BRCA1 gene. But at the same time, any woman with a similar mutation should not immediately run and remove her reproductive organs, since each case is individual, and the risks consist not only of genetic predispositions, but also biochemical changes, tumor markers and other indicators.
Genetic test is enough to pass once in a lifetime. The technique is this: first, it seems to screening and if it shows the mutation is a diagnostic test that will either confirm or refute the existing hypothesis. Now in Russia a lot of institutions allow you to do this.
The results of the genetic test yourself to interpret not necessary, as you can read a lot of literature and forums, to fall into hypochondria and do not get to the doctor. Appointment to search for a mutation of the BRCA1 gene is made by a specialist, and it is the geneticist who should interpret the results. It is not necessary to leave a person alone with the data. The patient is important to understand everything correctly. The BRCA1 gene is very large in General, and mutations in it can now be more than a thousand. To understand what mutation is found in humans and how it will affect the development of the disease, it is necessary to carry out a lot of work, to see all the scientific articles on the topic — it is engaged in a doctor-geneticist.
The identified risks are different. There are mutations that slightly increase the likelihood of developing the disease, they occur most often. In such cases, there is no need to do the operation, you need to carefully monitor your health. If it is proved that a certain mutation increases the risk of cancer up to 87 % (Jolie is so — indicative clinical case), it is necessary to make operational decisions.
If in every generation women die from bilateral breast or ovarian cancer, of course, removal of these organs is indicated.
Diagnostic tests are very accurate, and yet if a person does not trust any laboratory, he can redo the analysis in other institutions. Mutations in the gene is not a diagnosis and not an indication for surgery, but a statement that you need to be attentive to your health. The conclusion can only be made by a doctor after conducting examinations by several specialists (gynecologists, endocrinologists, etc.) and passing additional tests. In order to make predictions, it is important to take into account family history. If close relatives of a woman who was found to have a mutation, had cancer up to 40-45 years, she needs to be on the alert, starting with 35 years, and regularly undergo examinations. If in every generation women die from bilateral breast or ovarian cancer, of course, removal of these organs is indicated.
Now a lot of talk about breast cancer, according to the Ministry of health, in Russia it is already out on the first place in cancer mortality in women. Recently, cases of detection of this disease have become more frequent, but this is more likely due to the fact that diagnostic methods are improving. Preventive surgery to remove the mammary glands and ovaries are shown to prevent the development of cancer of these organs. But from other tumors it does not protect, so the patient who has suffered the disease, is increased cancer and increases the risk of intestinal cancer. Sometimes a colonoscopy is prescribed to treat the slightest inflammation and polyps before they turn into cancer.
After removal of the organs, replacement therapy is prescribed, and if it is correctly chosen, the patients do not feel any inconvenience. Many women after menopause, even without a high risk of cancer, are treated on the same principle. I see no reason why a woman after removal of ovaries would no longer be considered a woman: she gets enough hormones to feel good and look attractive. Any discrimination on the subject of health and the availability of certain organs seems unethical to me.
To paraphrase into normal English indignation of many a thing Jolie, then basically she is accused. The problem is that cancer phobia can be diagnosed only when there is no threat of cancer as such, or in cases where the patient, due to some circumstances, is little aware of the nature of his disease and suspects that its development will go some absurd way.
It would be ridiculous to argue that the fear for his life with 87% risk of breast cancer and 50% probability of ovarian cancer is groundless paranoia, it is also impossible to say that Jolie feeds any illusions or little knowledge about his condition. She explains her decision in sufficient detail, consistently and logically, without going to extremes or messianism, without calling on everyone to follow her. In my opinion, she behaves quite sensibly, and, unlike many observers, with the course diagnosed her neurosis, psychosis or gangrene of the brain, I can responsibly say that to diagnose anything like this remotely and based on the data gleaned in the media, just ridiculous. The rest if her family history, the occurrence of anxiety and phobic symptoms (which she denies, describing his expectation of results) would be not just surprising, and in General just did the most normal in this situation.
As for the public reaction, here everything is much more interesting. Why is everyone still so worried, as a person owns his own body and furthermore why logically the decisions it ostracize. On the one hand, each of us is very attached to his life roles. The question ” who are you?”first of all, a person will present his professional identity:” I am a lawyer”,” I am a student”,”I am a journalist”… But still in the first place is the role of gender, which is not presented precisely because it seems to be present by default. It is known, for example, that people feel uncomfortable until they can determine the gender of the interlocutor.
The loss of female reproductive organs and childbearing function is automatically associated in the minds of many with the loss of female identity, loss of self-identity, loss of purpose of existence. Even at that age and with the number of children, when the childbearing function itself does not seem to be important, the conscious rejection of the “most important” seems insane, can not be adequately perceived, and, of course, there is a transfer of the situation to his own “I”, which terrifies women, and men see a kind of protest against the Patriarchal system, where the female body itself with all its inherent functions is the object of service to his needs. In simpler terms, many, both women and men, sympathized with the “poor man” brad pitt, as if he had lost a woman (actually not) in the face of his wife.