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Actress' BRCA Testing, Surgery Choices Not for Everyone, Experts Caution

Actress' BRCA Testing, Surgery Choices Not for Everyone, Experts Caution

May 15, 2013 — After actress Angelina Jolie's disclosure on Tuesday of her preventive double mastectomy, doctors are cautioning that most women do not need genetic testing or surgery to avoid breast cancer, the Wall Street Journal reports (Beck/Winslow, Wall Street Journal, 5/14).

Writing in the New York Times, Jolie explained that she underwent a prophylactic mastectomy after discovering she had the BRCA1 gene, which greatly increased her risk of developing breast and ovarian cancer (Grady et al., New York Times, 5/14). Jolie urged other women "to find out through a blood test whether you are highly susceptible to breast and ovarian cancer, and then take action" (Kliff, "Wonkblog," Washington Post, 5/14).

Experts Raise Over-Treatment Concerns, Note Cost

Breast cancer advocates and experts praised Jolie for exploring her options and making informed treatment decisions, adding that her disclosure of her decisions might influence women with strong family histories of breast cancer to get genetic testing.

However, some doctors worried that Jolie's story might fuel a trend toward medically unnecessary mastectomies for early-stage breast cancer and preventive mastectomies of a healthy breast among women who have cancer in just one breast, even when their risk of a second cancer is a very low (New York Times, 5/15).

Cancer experts also cautioned that there is no need for women without family histories to undergo routine genetic testing for BRCA genes (Wall Street Journal, 5/14). They stressed that Jolie's condition is atypical; BRCA-related mutations are estimated to cause only 5% to 10% of breast cancers in the U.S.

"It's important to make it clear that a BRCA mutation is a special, high-risk situation," said Monica Morrow, chief of the breast service at Memorial Sloan-Kettering. For women at very high risk, preventive surgery is advised, but few women fall into that category, she said (New York Times, 5/14).

Otis Brawley, chief medical officer of the American Cancer Society, in a statement said, "While only a small number of breast cancers are linked to known genetic risk factors, women facing such a high risk need to know that, and need to be able to discuss their options with genetic specialists and knowledgeable health professionals so they can have all the information and expertise at their fingertips to do what's right for them." However, "[t]his does not mean every woman needs a blood test to determine their genetic risk for breast and/or ovarian cancer," Brawley added (Sun, Washington Post, 5/14).

Additionally, experts noted that BRCA testing can cost up to $3,000. Under the Affordable Care Act (PL 111-148), "[g]enetic counseling and BRCA testing, if appropriate, must be made available as a preventive service without cost-sharing" by health plans, the Department of Labor wrote in a March 9 guidance document. The U.S. Preventive Services Task Force has advised against BRCA screening for women without a family history of the related cancers ("Wonkblog," Washington Post, 5/14).

New York Times Columnist, USA Today Editorial Respond

A column in the New York Times and editorial in USA Today also discussed Jolie's announcement. Summaries appear below.

~ Maureen Dowd, New York Times: Jolie "knows that she will face criticism for elitism, given that she has the money to get the more than $3,000 BRCA testing and the best surgeons" to perform the double mastectomy, writes columnist Dowd. Nonetheless, Jolie is a "real-life action heroine" for "going public with the graphic details of her mutilation and reconstruction," Dowd says, adding that her announcement might help "ameliorate the stigma of disease and spark recognition, conversation and inspiration" (Dowd, New York Times, 5/14).

~ USA Today: Jolie's "message should give heart to other women facing such difficult choices, much as First Lady Betty Ford did by disclosing her own mastectomy in 1974, when breast cancer and mastectomies were rarely mentioned publicly," a USA Today editorial states. However, "it's equally important to note that Jolie is among an extremely small percentage of women with an unusually high risk of breast cancer due to her family history and her gene mutation," the editorial notes (USA Today, 5/14).