Jolie's pre-emptive mastectomies a courageous call

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“You have cancer” may be the most feared thing a doctor can tell a patient.

The diagnosis may be delivered in the gentlest terms, but the “C” word fills the room and captures the moment so everything said afterward is likely to be lost.

Oncologists learn to reassure, to promise the best possible treatment and to be available. An honest offer of availability is critical. Patients seldom abuse it when they know they can count on it.

Long explanations come later. The people sitting opposite their physicians are processing more than the specter of death. A dread of dependency, pain and disfigurement may be flooding their brains.

When I heard the story of Angelina Jolie’s double mastectomy, I recalled having that discussion with my patients.

Breast cancer threatens the way women see themselves and the way they are seen by others. During the past decade I worked in the breast referral clinic for Seattle’s Cancer Care Alliance, a collaborative program affiliated with the University of Washington. Women were given options grounded in statistics, but their decisions were driven by emotions.

Too many, in my opinion, foundered in concerns about whether they would be less desirable as a woman and less complete as a human being. I met some husbands who came to love and reassure them. Others thought that beauty was defined by the centerfold of Playboy.

Angelina Jolie may have to worry less than many of my patients, but she has dealt with a tough issue. Her courage may help others.

Her specific situation also raises questions about her genetic disorder. Her problem isn’t common. It doesn’t mean all women should run to their doctor and ask to be tested. The test could cost a few thousand dollars and your insurer probably won’t cover it, unless you are in a high-risk category.

BRCA1 — the letters are shorthand for BReast CAncer gene — carries a very high risk of developing cancer. Some media have used the figure of 87.5 percent. That may be a bit high, but more than 50 percent seems certain, and Jolie also has a risk approaching 50 percent of developing ovarian cancer.

The BRCA1 gene was discovered at the University of Washington in 1990, and BRCA2 was added a few years later.

I have previously discussed this type of gene in this column. In short, a gene is a segment of the DNA that exists in every cell of your body. These genes function as templates to make proteins.

The proteins perform many of the functions you need to live. In your stomach, they manage the early part of the digestive process. In your lungs, they reduce surface tension so the air pockets, alveoli, don’t stick together.

BRCA codes for proteins that keep cell division under control. If those genes are faulty, cell division moves toward mayhem. Cells that line the milk ducts run a high risk of becoming malignant and cells in the ovaries react in a similar way.

Women who have a diagnosis of breast or ovarian cancer, especially at a young age, should be tested. Since transmission occurs mainly from mother to daughter, the occurrence of breast or ovarian cancer in a woman is an indication for testing of her daughters and sisters. That is especially true if the cancer occurred at an early age.

More complete criteria exist. Check with your doctor.

I gave a lecture some years ago to a state meeting of the oncology nurses association. I made the mistake of exposing my feelings about the importance placed on a woman’s breasts, that the size and symmetry should meet some standard.

A nurse stood up and angrily challenged me with the question about how I would feel if I had to have “One of my parts cut off.”

As I said at the beginning, breast cancer is an emotion-laden subject.

Women consistently choose breast preservation procedures that offer the same cure rates as mastectomy. It usually requires more than a month of additional radiation or a radioactive implant.

It seems to me the decision belongs with the patient, but it’s sad to think she does it because she would be ugly otherwise. At the extreme end of my experience were patients who chose death over mastectomy.

I vividly recall a patient I treated years ago. She was an attractive 50-year-old brunette. Her mass was as hard as a baseball and nearly that size. The overlying skin was dimpled like the skin of a thick orange. She had no evidence of metastatic disease.

Her treatment should have been chemotherapy to reduce the tumor, followed by surgery and finishing with radiation to clear out the microscopic residual.

She said she wanted to die, rather than have her breast removed. Radiation reduced the tumor size but her mind was unchanged.

In future articles, I plan to clarify the way in which fear has resulted in over-promotion of screening. It simply isn’t as effective as we have believed.

I’ll also deal with positive areas of research and therapy. Lives are being saved that would have been lost in the early years of my medical career.

Dr. Larry Mulkerin is a retired clinical professor. He can be reached at mulkerin@charter.net.

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