March 24, 2014 — Angelia Jolie has revealed that she’s had more surgery to lower her risk of cancer. In an intimate essay in The New York Times today, the Oscar-winning actress discussed the difficult decision to remove her ovaries and fallopian tubes, a procedure that put her into forced menopause at age 39.
“I will not be able to have any more children, and I expect some physical changes,” she wrote. “But I feel at ease with whatever will come, not because I am strong but because this is a part of life. It is nothing to be feared.”
She said she will wear a small patch to replace estrogen and use an IUD to supply progesterone — two hormones that are reduced when the ovaries are removed. The progesterone will also help lower her risk of uterine cancer.
“I feel deeply for women for whom this moment comes very early in life, before they have had their children. Their situation is far harder than mine,” she wrote. Jolie has three biological children and three adopted children.
Genes Partially Led to Decision
“Quite frankly I was glad to hear she had done this because the risk of the ovarian cancer conferred by her mutation and her family history,” said Mary Daly, MD, PhD, chair of the department of clinical genetics at Fox Chase Cancer Center in Philadelphia. “I always get nervous with my patients if they keep putting off their [preventive surgery] for fear that they would have waited too long.”
Daly said having both the ovaries and fallopian tubes removed lower Jolie’s ovarian cancer risk by about 90%.
Two years ago, Jolie wrote about her decision to remove both her breasts. She knew at the time that she would eventually need further surgery to remove her ovaries, but she delayed it prepare herself “physically and emotionally” for the procedure and its consequences, she wrote.
Then a blood test revealed some troubling signs of inflammation, and she couldn’t wait any more. She had the surgery last week. Though no cancer was found, surgeons did remove a benign tumor on one of her ovaries.
“I did not do this solely because I carry the BRCA1 gene mutation, and I want other women to hear this. A positive BRCA test does not mean a leap to surgery,” she wrote.
Cancer Risk Is Small but Not Zero
She wrote that she wanted other women with BRCA mutations to know that surgeries like the ones she had are not their only options. It’s possible to lower your risk of cancer with medication, or to keep an eye out for early signs of cancer with frequent testing, a strategy called watchful waiting.
And she stressed that surgery is not a perfect solution.
“It is not possible to remove all risk, and the fact is I remain prone to cancer,” Jolie wrote.
In rare cases, even when the ovaries are removed, women can get cancer in the abdominal wall that acts just like ovarian cancer, Daly said.
For that reason, patients like Jolie continued to be followed with annual blood tests.
Jolie said she will continue to take steps to strengthen her health. But she feels good about the choices she’s made. “I know my children will never have to say, ‘Mom died of ovarian cancer,’” she wrote.
She said she wants other women at risk to know they have options to protect their health.
Measuring Jolie’s Influence
Studies have shown that in the 6 months after Jolie first disclosed her genetic risk and decision to remove both her breasts, the number of women who got tested for BRCA mutations doubled.
“We saw a real spike in interest” in the months after her original article, Daly said.
Daly said she thinks there were many women out there who knew they were at higher risk because of a family history but who also felt unsure of what to do about it.
“I think some of these women who don’t have cancer wonder, ‘Is this what I should really be doing? It’s drastic. My body will never be the same. Am I overreacting?’ And the fact that she came out and told their story made them realize this is not abnormal. This is OK for me to be thinking about,” Daly said.
Jolie’s essay received hundreds of comments in a short time on the New York Times’s web site. Many were from women who expressed their gratitude.
“I had the BRCA test done after reading about Angelina’s double mastectomy,” wrote a woman commenting as Joan Hobeck of Myrtle Beach, SC. “… Thank God I came back negative; however, the fear is still there. My mother died of ovarian cancer, as well as two of my Aunts, cousin with breast [cancer] and the list goes on. I am grateful for Angelina and her willingness to share her journey with us.”
Mitchell Maiman, MD, chairman of obstetrics and gynecology at Staten Island University Hospital in Staten Island, NY, agreed with that sentiment.
“I think it’s good. She’s very thorough when she discusses this,” Maiman said. “She’s a very intelligent woman and she gets all the science. She stimulates women to find out about their own risk and act on it.”
Jolie’s Advice Comes With Caveats
Daly said there were only two points in the article that she’d like to clarify.
The first is Jolie’s decision to start hormone replacement therapy.
“We don’t really know how safe it is for someone — even though they’ve had [their breasts removed] — to be on hormones for a prolonged period of time.”
Daly said studies suggest it might be safe for a short period of time, perhaps 3 to 5 years, but that Jolie still has a 10% risk of getting breast cancer.
“We worry about long-term hormone replacement therapy in any woman,” Daly said.
Jolie also mentioned that it might be possible for some women in the same situation to just remove their fallopian tubes but leave their ovaries to protect their fertility. Daly said most experts say more research is needed on that strategy.
“That’s an idea right now. That’s not a proven preventive option,” she said. “We don’t know how much risk protection just taking the fallopian tube out confers. It’s typically not considered a standard option.”