Tuesday, May 14, 2013

Angelina Jolie saved someone's life today

I am sure that Angelina Jolie did not write her letter in the NY Times with that intention in mind (http://www.nytimes.com/2013/05/14/opinion/my-medical-choice.html?_r=0).  But in her writing it is clear that she realized that she faced a difficult personal choice and knew that knowledge was empowering.  She has been on the forefront on informing the public about worldwide humanitarian crises, situations that we often don't want to hear about or know about because thinking about them seems too difficult to bear or comprehend.  In many ways, her personal story is just as difficult to hear about and to comprehend having to make the choices that she was faced with.

What Angelina Jolie revealed was the essence of how personalized choices in medicine can, and in my opinion, should be made.  Consultation with a genetic counselor can be the first step in the process.  There are certain patterns of disease in a family that may indicate the possibility of being a BRCA carrier.  The National Cancer Institute at the National Institutes of Health offers some guidelines to decide if testing is right for a particular person (http://www.cancer.gov/cancertopics/factsheet/Risk/BRCA).  One can choose to meet with a genetics counselor, review the family or personal history, and even defer genetic testing if that is their choice.

Angelina Jolie decided that understanding the 87% risk of developing breast cancer, that preventative (or risk reduction) double mastectomy was the right choice for her.  I think that early consultation with a plastic surgeon is vital to the decision making process.  Hearing about a double mastectomy from the breast surgeon without understanding the various options for immediate breast reconstruction can be difficult to process, and might make the surgical considerations seem more challenging than they might otherwise be.  With advances in surgical technology and treatment for preventative mastectomy, such as nipple areolar sparing surgery, direct-to-implant reconstruction, acellular dermal matrices in staged tissue expander to implant reconstruction, muscle sparing microsurgical abdominal surgery for transferring one's own tissue, and alternative donor sites for tissue transfer, preventative mastectomy can be a viable and empowered option for most women.

We are entering an age of personalized genomic medicine, where every individual cancer's genetic blueprint can offer us clues to customized treatment and prognosis. But we must not leave out the individual choices the patients' need to make to suit their needs, and the information that Angelina Jolie has shared will empower women to seek the knowledge that they need to make the right individual choice.

As Angelina wrote, "I wanted to write this to tell other women that the decision to have a mastectomy was not easy. But it is one I am very happy that I made. My chances of developing breast cancer have dropped from 87 percent to under 5 percent. I can tell my children that they don’t need to fear they will lose me to breast cancer."

As a physician interested in shared decision making and surgical decision making in breast cancer, I could not have said it any better.

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