On May 14, director and Academy Award-winning actress Angelina Jolie came forward in a New York Times op-ed about her struggle with cancer. “My doctors estimated that I had an 87 percent risk of breast cancer and a 50 percent risk of ovarian cancer, although the risk is different in the case of each woman … Once I knew that this was my reality, I decided to be proactive and to minimize the risk as much I could. I made a decision to have a preventive double mastectomy. I started with the breasts, as my risk of breast cancer is higher than my risk of ovarian cancer, and the surgery is more complex.”
Jolie had both of her breasts removed and reconstructed. For a woman known internationally as a sex symbol, this could not have been an easy decision. However, as expressed by Jolie, in a desperate situation like the onset of cancer, taking action offers a degree of control. For Jolie, the idea of her children living without her was enough to persuade her to take such a decisive action.
For hundreds of thousands of women worldwide, the rationale may be different, but the reality of the situation is all the same. Breast cancer is the second leading killer of women and the most commonly diagnosed cancer among women. It is estimated that more than 220,000 women in the United States will be diagnosed with breast cancer this year alone. More than 40,000 will die of the cancer. Among this number, many could not afford the screening needed to detect the cancer early, which would have saved their lives.
One in eight women will be diagnosed with breast cancer during the course of their lifetime.
Jolie’s decision was triggered by a prognosis that her BRCA1 (Breast Cancer 1, early onset) and BRCA2 (Breast Cancer 2, early onset) genes were mutated, exposing her to an increased risk of developing breast cancer. BRCA1 and BRCA2 are members of the tumor suppressor gene family, which regulates cell division and ensures that DNA breaks are corrected error-free. Mutations in these genes will produce a protein that may fail to correct chromosomal damage and may actually inhibit needed protein fabrication. Both BRCA1 and BRCA2 must be mutated for a person to contract Hereditary Breast Ovarian Cancer Syndrome (HBOC).
All known BRCA1/BRCA2 mutations are inherited, suggesting a link from a common ancestor. For example, BRCA2 mutation “6174delT” is found among Ashkenazi Jews, “C61G” is found among Germans and “6503delTT” among the Northern Irish. Jolie’s mother died of breast cancer after a 10-year struggle with the disease.
The population that may be carrying this mutation is staggering. While only a small percentage of the population will develop a mutation with either BRCA1 or BRCA2, and while the chances of getting both mutations is even smaller, the odds of getting cancer should a person have both mutations are almost a sure thing. Those that carry the BRCA1 mutation have a 60 percent lifetime likelihood of developin breast cancer, an up-to-60 percent chance of second breast cancer development, a 39 percent chance of ovarian cancer and an increased risk of other cancer types. BRCA2 mutation offers a 45 percent risk of breast cancer and increased risk of other types of cancer — including pancreatic, prostate, laryngeal, ovarian and stomach cancers and melanoma.
The economy of cancer testing
Despite this, many women cannot be screened for the mutation. Genetic testing can cost as much as $4,000 per test, and while most health insurance plans will cover the cost, the uninsured would find the cost prohibitive.
While according to the Susan G. Komen Foundation, one in 400 Americans will develop a BRCA mutation, the rates are different when considering different ethnicities. Asian-Americans stand a 1 in 200 chance of developing a BRCA1 mutation and a one in 39 shot at a BRCA2 mutation. For African-Americans, the odds are one in 76 for BRCA1 and one in 49 for BRCA2. For the Hispanic community, there is a one in 28 chance of a BRCA1 mutation.
Along with the increased odds of bearing a mutation, women of lower socioeconomic groups are more likely to have their case of cancer diagnosed at a later stage than those of higher incomes: In a study published in the journal BMC Cancer, 13 percent of lowest income women who were diagnosed with breast cancer were diagnosed after the cancer manifested in areas beyond the breast, compared with under 10 percent of the wealthiest women. Late diagnosis and lower adherence to recommended treatments are the two primary factors.
Biological factors play a significant, but minor role in survival rates. Black women were found to survive at a rate under 80 percent one year after diagnosis, compared with 90 percent among women of other races. The Susan G. Komen Foundation recognizes that premenopausal African-American women have a 10 to 50 percent additional risk of developing breast cancer.
However, making such distinctions can be foolhardy, considering that researchers know so little about breast cancer. For example, as reported by the California Breast Cancer Program, among California women, the top 20 percent among White women in regard to earning power and education are 27 percent more likely to get breast cancer than the bottom fifth. Among African-American women, that difference is 22 percent; 83 percent among Hispanic women and 65 percent with Asian women. It may be that the likelihood of breast cancer detection among the bottom fifth is less, but this has yet to be proven scientifically.
In such an environment of uncertainty, precaution and awareness are all the more essential. “For any woman reading this, I hope it helps you to know you have options,” Jolie wrote. “I want to encourage every woman, especially if you have a family history of breast or ovarian cancer, to seek out the information and medical experts who can help you through this aspect of your life, and to make your own informed choices.”
“I wanted to write this to tell other women that the decision to have a mastectomy was not easy. But it is one I am very happy that I made. My chances of developing breast cancer have dropped from 87 percent to under 5 percent. I can tell my children that they don’t need to fear they will lose me to breast cancer.”