Oncologist, geneticist and psychotherapist on the removal of the breast and ovaries
Yesterday actress and director Angelina Jolie published a column in The New York Times, where she spoke about her fight against the threat of cancer. Following a double mastectomy, that is, the removal of both mammary glands, Jolie underwent an operation to remove the ovaries and fallopian tubes. She spoke about the process of making this difficult decision and urged women to be attentive to their health and to understand that the disease detected in time or its adequate prevention increases the chances of a long and happy life. The column caused a violent resonance in social networks, including negative reviews - Jolie was accused of alarmism, carcinophobia and in the promotion of inappropriate treatment methods.
A large number of comments condemning the actress confirmed that with all the progress in technology and diagnostics, many still prefer not to know or not to think about a potential problem until thunder claps, and the awareness of Russians about cancer prevention and how to treat them is far from ideal. Another reason for such a negative reaction to the removal of the reproductive system at a similar age lies in the stigmatization of such operations and the women who transferred them - in a child-centered society, “cutting off everything” automatically means “to stop being a woman” and “to lose value” in the eyes of men. We asked the surgeon-oncogynecologist who took part in the treatment of mother of Angelina Jolie, as well as the genetics and psychotherapist to comment on this situation and talk about new technologies and current methods of prevention and treatment of female cancers, which everyone should know about.
Every eighth woman in the world suffers from breast cancer. In Russia, the situation is somewhat worse, because in our country women often neglect early diagnosis and doctors do not know it well enough, for example, they often replace mammography with ultrasound or even a simple examination of the mammary glands. With breast cancer, as with any other type of cancer, it is very important to diagnose it as early as possible, then there is a greater chance of curing it. Survival depends on the stage at which the disease was found. But there are, of course, many other nuances. For example, some tumors are hormone-sensitive, and in such cases the prognosis is better. There are a number of tumors that do not have hormone receptors, they are often more aggressive, respond to chemotherapy worse and, accordingly, are not treated with hormonal drugs.
Fortunately, there is an early diagnosis of breast cancer - for most diseases it does not. If you follow the recommendations of doctors and after 40 years to undergo a mammogram once a year, then the probability of not dying from breast cancer increases significantly. Women from 30 years old need to visit a mammologist and do an ultrasound of the mammary glands every three years, and this is on condition that they have no particular problems with the mammary glands, there were no lumps, neoplasms and the patient does not have a genetic predisposition to cancer same Angelina Jolie.
The genetic risk of developing breast or ovarian cancer is a family history of cancer. If your mother, grandmother, or aunt at a young age had premenopausal cancer (that is, breast or ovarian cancer - they are often combined into one syndrome), you are at risk. Chance to get cancer in this case increases tremendously. Of course, there are sporadic cases of the disease, but there are certain syndromes, as in the case of Angelina Jolie - BRCA1 and BRCA2. For carriers of the first type of mutation, the risk of developing breast cancer at one or another age is 85%, that is, it is virtually every first carrier.
Genetic tests can reveal if there is a mutation. Doctors make conclusions about risks, they look at the type of mutation and further everything is already known. It is much more important for a gynecologist or a mammologist to correctly collect anamnesis. I always ask patients who come with conditional thrush or cervical dysplasia, what their relatives were sick with, what degree of kinship and at what age they suffered a disease. When a woman says: “My aunt died of breast cancer at the age of 45, my grandmother had ovarian cancer and her mother had a tumor, but it seemed benign and she was cut out,” the doctor should understand that the patient needs to be checked for the carrier of these mutations. Usually we test women whose relatives suffered cancer of the ovaries or mammary glands at a young age; those who already have breast or ovarian cancer before the age of 50; and women who undergo multiple biopsies about the formations of the breast, seemingly benign, but not completely understood. It so happens that a woman has a very convincing family history of certain oncological diseases, but for some reason there is no mutation in her. In such cases, we sequence the whole BRCA1 and BRCA2 gene and see if there is a mutation in some atypical loci (places), and often we find it there.
Routinely pass genetic tests makes no sense. Moreover, if the parents have a mutation, we recommend that they not test children before they reach the age of 20-25. The risks of cancer begin to grow at 30-35, so, apart from anxiety, this information will not add anything to parents. After 20 years, according to the results, we warn you: your risk of getting cancer before the age of 35 is quite low and you have a chance to realize reproductive function until that time to the extent that you want. However, there is no harm from such tests, except financial: a test for the most common mutations will cost 15-17 thousand rubles.
Every fourth carrier of the first type of mutation dies from ovarian cancer. Such a sad statistic
I spent nine years in the United States and participated in the treatment of Angelina Jolie's mom when she had a relapse of ovarian cancer. She was then 54 years old, and she died at 56 from breast cancer. She identified two mutations at once, both of the first and second types. In their family, indeed, almost all women suffer from breast or ovarian cancer. For all my patients who have a mutation, I explain for a long time what the risks are. Fortunately, in cases of breast cancer, we have intensive screening protocols: we begin to monitor the state of mutation carriers much earlier than usual, up to 25 years, every six months we alternate mammography and MRI of the mammary glands, examines the mammologist. If you comply with these conditions, it is possible to postpone the removal of the breast.
With the ovaries, everything is much worse: among carriers of the first type of mutation, the probability of getting ovarian cancer is 54% - that is, every second woman. Unfortunately, 80% of patients learn about it when the cancer is already in the third stage. At this stage, the survival rate even with the most aggressive treatment is 35% at best. That is, every fourth carrier of the first type of mutation dies from ovarian cancer. Such a sad statistic. For this reason, knowing that the risk increases at the age of 35, I recommend to all my patients who carry the BRCA1 and BRCA2 mutations that prophylactic removal of the ovaries and fallopian tubes by laparoscopic means.
Such preventive surgery significantly reduces the risk of cancer, but does not reduce it to zero. In 7-10% of cases during removal of the ovaries, we already detect a microscopic tumor. This means that we are late with prevention and the cancer has already begun to develop. There is also a subtype of ovarian cancer called primary peritoneal carcinoma - this is actually the same ovarian cancer, but it does not begin on the ovaries themselves, but on the surfaces of the peritoneum. It can occur even after removal of the ovaries and fallopian tubes in carriers of mutations. With less probability, but it is impossible to exclude it. We always warn women that they can get ovarian cancer, even if there are no ovaries, no matter how paradoxical it may sound.
Patients respond to preventive surgery in different ways. Those who have relatives dying from cancer in their eyes sometimes come and ask themselves to remove the ovaries and fallopian tubes. Another thing is when a woman of forty falls ill with breast cancer and we detect a mutation in her - at that age it is more difficult to say goodbye to the ovaries, especially if the patient has no children. Then we start the race: we ask the woman to get pregnant and give birth as quickly as possible and after that we already remove the ovaries. The problem of 40-year-old women is that they often cannot get pregnant quickly - the ovarian reserve is usually not very good by this age. A reproductive specialist comes to the rescue, he performs IVF, receives and freezes eggs or embryos, and only then we remove the ovaries, and the woman can endure this pregnancy without the ovaries.
Physically, the operation to remove the ovaries of the patient is easily tolerated. The procedure takes 30-40 minutes. A woman comes to the clinic on the day of the operation a couple of hours before the start and goes home the next day, if necessary, she takes a sick leave for 3-4 days. Psychologically to cope with this more difficult. After removal of the mammary glands and ovaries, women begin to perceive themselves differently, it changes them psychologically. Although it all depends on the person. Many patients after mastectomy immediately put implants and live as before, enjoying a low risk of developing breast cancer. There is no option to put implants with ovaries. Removing the ovaries, for example, at the age of 35, a woman enters menopause. She starts menopause, and it adds a number of physical and psychological problems. Theoretically, they can be solved or facilitated using hormone replacement therapy (HRT), but there are some difficulties, because with prolonged use of HRT alone can provoke the development of breast cancer. Therefore, many women refuse hormone therapy and take some form of non-hormonal drugs that help fight ebb and flow, mood swings and everything else. With regard to sexual life, patients with ovaries removed complain of vaginal dryness and sometimes decreased libido, but the latter’s dependence on the presence / absence of ovaries has not yet been proven.
Angelina Jolie passed the analysis on the gene mutation, the risk of developing the disease was estimated based on her pedigree. I think she did a survey on a number of other indicators. Most likely, the actress decided to mastectomy not only on the basis of a genetic test - of course, an integrated approach is important here. A few years later, Jolie had surgery to remove the ovaries. This step is understandable, because in women in natural menopause the risk of ovarian cancer increases. For her, it was a justified preventive measure, taking into account the mutation of the BRCA1 gene. But at the same time, any woman with a similar mutation should not immediately run away and remove her reproductive organs, since each case is individual, and the risks are not only genetic predispositions, but also biochemical changes, tumor markers and other indicators.
A genetic test is enough to pass once in a lifetime. The technique is as follows: screening is first taken, and if it shows a mutation, a diagnostic test is conducted that allows you to either confirm or refute the existing assumption. Now in Russia, many institutions allow it.
The results of the genetic test should not be interpreted independently, as you can read a lot of literature and forums, fall into hypochondria and don’t get to the doctor. The appointment to the search for the BRCA1 gene mutation is made by a specialist, and it is the genetic physician who must interpret the results. Do not leave the person alone with the data. It is important for the patient to understand everything correctly. The BRCA1 gene is generally very large, and there may now be more than 1,500 mutations in it. To find out what kind of mutation is found in a person and how it will affect the development of the disease, it is necessary to do a lot of work, to see all the scientific articles on the topic - this is done by a geneticist.
Identified risks vary. There are mutations that slightly increase the likelihood of developing the disease, they are most common. In such cases, there is no need for surgery, you need to carefully monitor their health. If it is proved that a certain mutation increases the risk of cancer to 87% (for Jolie, this is an indicative clinical case), then operational decisions need to be made.
If in every generation women die from bilateral breast or ovarian cancer, of course, removal of these organs is shown.
Diagnostic tests are very accurate, and yet if a person does not trust any laboratory, he can redo the analysis in other institutions. Mutations in the gene - this is not a diagnosis and not an indication for surgery, but a statement that you need to be attentive to your health. The conclusion can only be made by a doctor after examinations with several specialists (gynecologists, endocrinologists, etc.) and additional tests. In order to make predictions, it is important to consider family history. If the close relatives of a woman who has found a mutation, fell ill with oncology before the age of 40-45, then she needs to be on guard from the age of 35 and have to undergo regular examinations. If in every generation women die from bilateral breast or ovarian cancer, of course, removal of these organs is shown.
Now there is a lot of talk about breast cancer, according to the Ministry of Health, in Russia it is already coming to the first place in oncology mortality among women. Recently, cases of detection of this disease have become frequent, but this is due, rather, to the fact that diagnostic methods are improving. Preventive surgery to remove the mammary glands and ovaries are indicated for the prevention of the development of cancer of precisely these organs. But this does not protect against other tumors, therefore, the patient who has undergone the disease has increased onconference and increases the risk of intestinal cancer. Sometimes a colonoscopy is prescribed to cure the smallest inflammations and polyps before they develop into cancer.
After removal of the organs, replacement therapy is prescribed, and if it is properly selected, the patients do not feel any discomfort. Many women after menopause, even without a high risk of developing cancer, are treated on the same principle. I see no reason why a woman would no longer be considered a woman after the removal of the ovaries: she gets enough hormones to feel good and look attractive. Any discrimination on the subject of health and the presence of certain organs seems unethical to me.
If to rephrase into a normal language the indignation of many by the act of Jolie, then basically she is accused of carcinophobia. The problem is that cancer phobia can be diagnosed only when the threat of cancer does not exist as such, or in cases where the patient, due to some circumstances, is little aware of the nature of his illness and suspects that its development will go to something absurd. by.
It would be ridiculous to argue that fears for their lives at 87% risk of breast cancer and a 50% chance of ovarian cancer is groundless paranoia, it is also impossible to say that Jolie feeds any illusions or is little aware of her condition. It explains in detail, consistently and logically its decision, without going to extremes or messianism, not urging everyone to follow her. In my opinion, she behaves quite sensibly, and, unlike many observers who diagnosed her neurosis, psychosis or gangrene of the brain, I can declare with full responsibility that I can diagnose something like this remotely and based on the data obtained in The media is just ridiculous. Otherwise, with her family history, the occurrence of alarming-phobic symptoms (which she does not deny, describing her expectation of results) would be not only not surprising, but in general just the most normal in the current situation.
As for the reaction of the public, here everything is much more interesting. Why everyone is still so worried about how a person disposes of his own body, and moreover, why he is ostracized for his logical decisions. On the one hand, each of us is very attached to his own life roles. To the question "who are you?" first of all, a person will present his professional identification: “I am a lawyer”, “I am a student”, “I am a journalist” ... But still, the gender role comes to the first place, which is not presented precisely because, as it were, is present by default. It is known, for example, that people feel uncomfortable, until they can not determine the gender of the interlocutor.
The loss of the female reproductive organs and the childbearing function is automatically associated in the minds of many with the loss of female identity, loss of selfhood, and loss of purpose for existence. Even at that age and with the number of children, when the child-bearing function itself would seem to be irrelevant, a conscious rejection of the "most important" seems insane, cannot be adequately perceived, and, undoubtedly, the situation is transferred to its own " я", что повергает женщин в ужас, а мужчинам видится неким протестом против патриархальной системы, где само женское тело со всеми ему присущими функциями является объектом служения для его потребностей. Говоря более простым языком, многие, как женщины, так и мужчины, посочувствовали "бедняге" Брэду Питту, как бы утратившему женщину (на самом деле нет) в лице своей жены.
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