October 16th, 2013


Angelina Jolie, the 21st century’s sex symbol, makes a public statement about her breasts and ovaries, and it turns our world upside down about how we think about, talk about and react to breast cancer.


Angelina has clout that pours off her status as the Hollywood icon. Beyond being Brad Pitt’s partner and mother of six, she’d already been a 10-year veteran as a globe-trotting UNHRA Ambassador, a front and centre spokesperson at the United Nations on war rape  and a generous humanitarian.


So on Feb. 16 of this year,  at the age of 37, forewarned by doctors that she had an 87 per cent risk of developing breast cancer due to a defective gene identified as a BRCA1, Jolie underwent a preventive double mastectomy.


Her family history had already told the tale of a greatly increased risk even before she underwent testing to confirm it. Her mother, actress Marceline Bertrand, had breast cancer and died from ovarian cancer at the age of 56: her maternal grandmother had ovarian cancer, dying at 45. Her maternal aunt Debbie Martin, with the same defective BRCA1 gene, was diagnosed with breast cancer in 2004 and died at age 61 earlier this year .


Jolie’s mastectomy lowered her chances of developing breast cancer to less than five per cent, which is about the same as the female population in general.


By April 27, when she went public, Jolie had already had reconstructive surgery involving implants and allografts. So there was really nothing – or everything  – to see, depending on your point of view.


So why did she choose to go public about her decision? For sure, it lent her impressive heft to open the door for women to access the expensive BRCA testing in America. It was an acknowledgement that this testing – at $1,500 a test – isn’t readily available to millions of American women. Even though the gene accounts for less than one per cent of breast and ovarian cancers, it carries a devastating trajectory, killing women every year and well before their time.


In Canada, BRCA testing is a matter of sitting down with genetic counsellors attached to the familial breast cancer units in many hospitals and undergoing a risk assessment. Based on those results, you’ll then discuss the advisability of having the test. Over the past 10 years, a number of my patients have chosen to go ahead with the test – all have been rewarded with negative results. In other words, they don’t have the BRCA gene.


Only one patient, who had been advised that her risk was low, insisted rather forcibly on having it done. Her family and roots had been decimated in the war in Europe in the ’40s, but she fit the profile of an Ashkenazi Jew springing from middle European stock, who have a much higher genetic propensity for BRCA.  She wasn’t shocked when she tested positive. Her response, like Jolie’s, was to have a prophylactic double mastectomy. Older than Jolie, she also elected to have her ovaries and tubes removed. This removed any chance that the hormone estrogen, produced by her ovaries, would be there to stimulate the growth of cells gone awry in breasts or ovaries or pelvic organs.


When and if Angelina will walk the same path is a matter of speculation, though it’s likely she won’t overvalue her status as a sex-goddess icon to the detriment of her life. Leaving that swell of fame – one of the world’s most beautiful women – to become a crone ahead of her time is something that one can see this bred-in-the-bone radical doing with impunity.


But it’s clear that being post-menopausal isn’t conducive to the image of what Hollywood demands in its sexually sensational All-Stars. Angelina will have to forgo her persona to save her life. After all, she is only 38 years old. Is there a hint of such a shift already? She has recently announced her second directorial project – the story of the 1936 Olympic marathoner Louis Zamperini whose life has been retold in Laura Hillenbrand’s feature film, Unbroken.


For the moment we have no way of effectively predicting the onset of ovarian cancer even in high-risk women such as Jolie. The standard recommendation in these high-risk women is to remove the ovaries and tubes, certainly by the early 40s.


Many studies have been devoted to monitoring “serial Ca125”, doing pelvis ultrasounds every six months to detect changes and conducting regular clinical pelvic examinations. All have failed to reassure the very women most in need of this information so that they can plan for such definitive and conclusive surgery as prophylactic removal of the pelvic organs that virtually defines femaleness.


And so, many years and research papers later, are we any further ahead in knowing how to stay alive with breast cancer?


The star power of Jolie is a plus in bringing the issue of genetic testing, its limits and costs, its value and its rarity to the attention of millions of women around the world. Her public face can only help diffuse the secrecy about mastectomies and reconstructions and raise the profile of the choices that are open to women. But it underscores the still serious limitations, even now, that genetic models can create a whole new world of treatment and prevention for breast cancer. The vast majority of women as they age, because they age, will find that breast cancer will continue to dog them well past menopause. In that, they will have common ground with Angelina.


Dr. Jean



Doctor. Writer. Athlete.

Advocate. Adventurer.