OPINION

Opinion: Angelina Jolie’s transparency sheds light on standard but unknown procedure for high-risk women

Angelina Jolie meets members of the Yazidi minority in Khanke IDP Camp on January 25, 2015 in Khanke, Iraq.

Angelina Jolie meets members of the Yazidi minority in Khanke IDP Camp on January 25, 2015 in Khanke, Iraq.  (2015 UNHCR)

On Tuesday, Angelina Jolie Pitt publicly announced that she had her ovaries and fallopian tubes removed to decrease her risk of developing ovarian cancer, a highly lethal cancer that at present has no screening test to detect it at an early, curable stage. Jolie Pitt has shared that she inherited a mutation in the BRCA1 gene. Women with a BRCA1 gene mutation have a remarkably high lifetime risk of developing ovarian cancer of 40-50 percent as well as a nearly 80 percent lifetime risk of breast cancer.

RRSO is not indicated for all women. The decision to undergo RRSO requires a careful, individualized discussion of the risks and benefits. Removing the ovaries means immediate menopause.

- Jamie N. Bakkum-Gamez, M.D.

As a gynecologic oncologist (a doctor who treats cancers of the female reproductive tract), I care for women with ovarian cancer every day and this is a devastating disease. Together, women, their families, and their team of cancer providers battle this aggressive cancer. Treatment is most often an extensive and long, with surgery that requires hospitalization followed by five months of chemotherapy. Both surgery and chemotherapy are indicated for most women with ovarian cancer and both carry substantial risks of complications. After chemotherapy, we watch for signs of the cancer coming back. In too small of a proportion of women, it does not come back. Among the majority, return of the cancer means they will ultimately die from it. 

The women I care for are strong and heroic. They are also mothers, wives, daughters, sisters, and friends. There is a desperate need for a screening test to detect this cancer early and researchers are dedicating their careers to developing one. But we don’t yet have the equivalent of a mammogram or colonoscopy to detect ovarian cancer at a highly curable stage.

Jolie Pitt underwent a surgical procedure that, in medical terms, is called a “risk-reducing bilateral salpingo-oophorectomy” or “RRSO” and it is the only preventative intervention that has been shown to decrease death from ovarian cancer. This is a surgical procedure that for many years has been recommended to women identified to be at high risk for ovarian cancer. 

Jolie Pitt’s transparency with her own health prevention has shed important light on a procedure that has long been considered the standard of care for high-risk women. 

RRSO reduces the risk of ovarian cancer by >90 percent and I recommend it to all of my patients who are at a higher than average risk of ovarian cancer secondary to a known inherited gene mutation or a strong family history of ovarian and/or breast cancer.  

The National Comprehensive Cancer Network’s consensus guidelines from physician experts around the U.S. recommends that women who are considered high risk undergo RRSO between the ages of 35 and 40 or when childbearing has been completed. Prior to that, semi-annual pelvic ultrasound to image the ovaries as well as a blood test, CA-125, is recommended. 

It is important to note that these tests and RRSO are only indicated for women at high risk. Also, even though these tests are recommended, they have not been shown to detect ovarian cancer at earlier stages and have not been shown to improve survival from ovarian cancer. Thus, at present, our best medical evidence supports RRSO for women at high risk for ovarian cancer.

It is also important to note that the lifetime risk of ovarian cancer in the average risk female population is only about 1.3 percent and that there are non-surgical interventions such as taking birth control pills, giving birth, and breast-feeding that decrease the likelihood of developing ovarian cancer among all women.

However, in high-risk women, these interventions carry a fraction of the cancer risk reduction that RRSO provides and these interventions have not been shown to reduce the risk of death from ovarian cancer.

RRSO is not indicated for all women. The decision to undergo RRSO requires a careful, individualized discussion of the risks and benefits. Removing the ovaries means immediate menopause. The risks associated with early menopause include hot flashes, decreased libido, and vaginal dryness, but also there is evidence of risks to bone, heart, and brain health. Some of these risks can be mitigated by hormone replacement. However, unless there is an indication for removal of the ovaries, such as a high risk for developing ovarian cancer, the benefit of keeping them likely outweighs the risk of having them removed.

Jamie N. Bakkum-Gamez is a gynecologic oncologist at the Mayo Clinic in Rochester, Minnesota.

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