Decisions made to manage risk inevitably involve weighing up alternative actions according to their potential benefits and consequences. This is the concept of ‘risk versus reward’ that surely formed a big part in Angelina Jolie’s recent decision to have a double mastectomy and to ‘go public’ with her story. In an opinion piece in the New York Times, Jolie told of how her decision to have the complex surgery, which spanned over three months, was prompted by the knowledge that she had inherited a defective gene that increased her risk of developing breast cancer to 87%. She wrote that “once I knew that this was my reality”, she decided to “be proactive and minimise the risk” of cancer, to which her mother at age 56 sadly lost her battle. According to the ABC, Jolie expressed the satisfaction that the surgery has afforded her in knowing that her children will not have to worry that they will lose her to breast cancer. Jolie wrote in her opinion piece in the New York Times, "For any woman reading this, I hope it helps you to know you have options”.
The Breast Cancer Network Australia (BCNA) has thanked Jolie for speaking out, and as CNN News reports, reminded women that “the option is always there” in Australia for the same quality of surgery technique that Jolie had access to. However, the BCNA also noted in the ABC News article that “most breast cancers are not hereditary”, and that only 5-10% of breast cancer victims carry or have a family member that carries the ‘faulty’ gene. Jolie’s revelation will indeed raise the public profile of the options for minimising the risk of breast cancer, and be a source of courage for women that were already considering surgery. However as the World Health Organization reports, the majority of women lost to breast cancer each year are in “low- and middle-income countries”, while the cost of genetic testing for the ‘faulty’ breast and ovarian cancer gene is over US$3,000.
Notwithstanding the hefty costs of testing, surgery and breast reconstruction, the fact remains that even a “radical” double mastectomy will leave the woman with a 10% chance of developing breast cancer “in the armpit, chest wall or even abdomen”, and so does not completely eliminate the risk. As CNN News points out, the surgery also carries the risks of all major operations, and can have psychological repercussions for women who cannot afford ongoing therapy.
Cancer Australia points out that the downside of regular mammograms to detect breast cancer should be considered, such as “false-negative or false-positive results, over-diagnosis, overtreatment, and radiation exposure”. The New England Journal of Medicine publicised the results of a study of screening that found that there “has been no decrease in the incidence of metastatic cancer since the introduction of screening”, and pointed out that screening “readily finds tumours that are so slow-moving they might never metastasize”.
The New York Times suggests that Jolie has “done a real service for women around the world” by publicising her story, however this highly influential role model has taken what might be considered an extreme option that should not be misinterpreted as best practice to completely eliminate the impact that the frightening disease has on women around the world.