Elective Surgery to Prevent Cancer: What You Need to Know
Earlier this week, Hollywood movie star and UN ambassador Angelina Jolie Pitt announced her decision to undergo an elective bilateral salpingo oophrectomy, or BSO. In everyday terms, it is the surgical removal of both ovaries and Fallopian tubes. She did it for prophylactic, or preventative, purposes due to her genetic predisposition to contract ovarian cancer.
As Ms. Jolie Pitt brings to awareness the issue of prophylactic cancer surgery, many people will be wondering: How do I determine if I am a candidate for such a procedure? This article will shed some light on this matter.
First and foremost, it is extremely important to understand that only certain patients qualify for such a measure. According to the American Cancer Society, about “5-10% of all cancers are directly due to genetic defects (also known as mutations).” Two of the most common family cancer syndromes are hereditary breast and ovarian cancer syndrome. This is due to the mutation of the BRCA genes, which consist of BRCA1 and BRCA2 genes. In general, everyone has these genes. According to the National Cancer Institute, they produce tumor suppressor proteins which are responsible for ensuring “stability in the cell's genetic material” by repairing damaged DNA. However, when a specific inherited mutation takes place, the risk for female breast and ovarian cancer increases dramatically. According to Antoniou et al. and Chen et al., the lifetime risk for breast cancer in women increases from 12% (no mutation) to 55-65% for those with the BRCA1 mutation, and 45% for those with the BRCA2 mutation. The same studies also state that the lifetime risk for ovarian cancer increases from 1.4% (no mutation) to 39% for those with the BRCA1 mutation and 11-17% for those with the BRCA2 mutation. All of the percentages quoted are the risk by age 70. These numbers will continue to change as more medical research is published.
Besides the BRCA mutations, another family cancer syndrome known as familial adenomatous polyposis (FAP) may result in undergoing prophylactic surgery. In this case, numerous polyps form in the epithelium of the colon/large intestine. The polyps typically start out benign, but if untreated, they transform into a malignant stage. The primary genetic cause is a mutation in the APC gene, which is also a tumor suppressor gene. Colorectal cancer develops due to FAP at the average age of 39. If you have a family history of breast cancer, ovarian cancer, or FAP, consider genetic testing. The earlier it is done, the easier it will be to develop a lifestyle change and/or treatment plan.
When is preventative surgery necessary? For the most part, preventative surgery is determined between the surgeon and the patient. If the patient presents with the aforementioned genetic predispositions and a strong family history (first and/or second generation) of breast, ovarian, or colorectal cancer respectively, then they would be strong candidates to have the surgery.
When patients are considering prophylactic surgery, they need to consult a team of medical professionals. The New York Times published an op-ed by Ms. Jolie Pitt about her recent prophylactic BSO experience. She stated that because she tested positive for the BRCA1 mutation and given the fact that her mother and grandmother died of cancer, she started to consider preventative surgery. However, Ms. Jolie Pitt did what I always state at the end of my pieces: she consulted a qualified medical team in order to determine the best course of action. Her op-ed states that she consulted physicians from both the East and the West, investigating different types of medicine (Western and alternative). In addition, she also took the extra step and looked at hormonal therapy since a BSO would make her go into menopause. Her efforts in doing all of the necessary research to be an informed patient deserve the highest commendation.
According to a 2010 article by Domchek et al. published in the prestigious JAMA journal, women who underwent a prophylactic BSO reduced their risk in dying from ovarian cancer by nearly 80%, and a more than 50% reduction in the risk of dying from breast cancer. The prophylactic surgery involved in patients who have been diagnosed with familial adenomatous polyposis (FAP) either involves the removal of the colon and the rectum, or only the colon. At present, the surgery of choice is typically rectum saving. However, it can lead to a higher postoperative incidence of cancer so consult a medical professional if you have FAP.
Although preventative mastectomies, salpingo-oophorectomies, and colectomys/proctocolectomys may seem like an extreme measure, when a patient has a genetic predisposition and a strong family history, it should be considered. There are risks for any surgical procedure, so it is important to consult a medical team in order to understand your options. Talk to your doctors, and if it is confusing, ask them to re-explain. Despite the risks, surgery does give closure that it is highly unlikely that cancer will arise and develop from those regions. Ms. Jolie Pitt stated that all of the physicians both East and West recommended surgery given her specific case. In the end, you need to do what you feel is best, but please make sure that you do so after soundly educating yourself about your options and overall prognosis.
About SC Ali
S.C. Ali is an author/editor. He has a degree in Chemistry, and is interested in the study and practice of medicine. His blog can be found here: http://thebronzelifestyle.com/