"My children will never have to say, 'Mom died of ovarian cancer.'”

The actor Angelina Jolie is in the news again for bravely stepping forward and making public the difficult health decisions to minimize her elevated risk for breast and ovarian cancer caused by a mutated BRCA1 gene. In a New York Times piece, she described her thought process to have her ovaries and fallopian tubes removed. I believe that sharing her experiences could benefit others.

In a previous courageous public announcement she disclosed how she opted to have a prophylactic mastectomy. Breast and ovarian cancer run in her Mom's side of the family. Her maternal grandmother died of ovarian cancer when she was 45. Her mother battled with both breast and ovarian cancer before succumbing when she was 56. Her aunt (mother's sister) died of breast cancer. A genetic test revealed that Ms Jolie carries a mutant allele (version) of the BRCA1 gene (like her Mom and GrandMom), and that this mutant gene conferred an approximate 87% risk of breast cancer and 50% risk of ovarian cancer. The breast removal surgery greatly reduced her risk of breast cancer.

In the piece she mentioned how she delayed her decision about having her ovaries removed. Although much less common than breast cancer (lifetime risk is about 1.5%), ovarian cancer is particularly deadly; the one-year survival rate is 75% and the five-year survival rate is less than 50%. It is also very hard to detect. However, her mindset changed when a routine blood test revealed inflammation that could indicate the presence of early cancer. Further tests did not show any signs of cancer, but the news galvanized her resolve to go ahead with the operation:

"Last week, I had the procedure: a laparoscopic bilateral salpingo-oophorectomy. There was a small benign tumor on one ovary, but no signs of cancer in any of the tissues."

This is very good news.

One consequence of the surgery is that Ms Jolie will enter premature menopause. Without ovaries a woman begins menopause because of the loss of estrogen and progesterone production. However this will be delayed because Ms Jolie is taking hormone therapy to help reduce of the risk endometrial cancer, a type of cancer of the uterus. She could have had her uterus removed too in the operation (hysterectomy) but chose to keep it. It is possible that she is planning to have more kids. At some point it makes sense to remove her uterus and then stop the hormone therapy (see below).

At the end of her personal essay, Ms Jolie concludes with the following:

"It is not easy to make these decisions. But it is possible to take control and tackle head-on any health issue. You can seek advice, learn about the options and make choices that are right for you. Knowledge is power."

Knowledge is power indeed. It is very important that Ms Jolie encourages people in a similar situation as hers to consult with doctors and top medical experts to make the best possible medical decision. In that vein, I reproduce the following fact sheet from the Washington Post:

1. How common is ovarian cancer? About 21,000 women will be diagnosed with ovarian cancer this year, according to Richard Wender, chief cancer control officer at the American Cancer Society, and 14,000 will die during that period.

2. But Jolie is at much higher risk? Yes. She carries a mutation of the BRCA1 gene most common in Eastern European Jews that gives her an 87 percent chance of developing breast cancer and a 50 percent chance of developing ovarian cancer, according to her article. Plus she has a long history of women in her family dying of cancer, including her mother, who was diagnosed with ovarian cancer at age 49.

3. But Jolie doesn't have cancer. Why did she have her ovaries removed? The sad reality is that there is no reliable screening for ovarian cancer, experts say. Most ovarian cancers are discovered in the later stages of the tumor's progress, often after they have metastisized to other parts of the body, making treatment very difficult.

4. So is this some kind of special analysis available only to the wealthy and famous? No. This is the current standard of care.

5. What are the consequences of the surgery? Jolie is now in very early menopause. She is taking hormones, though that practice is controversial, Meyers said, and some women who have had breast cancer cannot be put on hormones.

As stated above, Ms Jolie is taking hormones (i.e. estrogen and progesterone) to reduce the risk of uterine cancer; she is keeping her uterus perhaps because she wants to have more kids. Being put on hormones is controversial because estrogen and progesterone can promote the growth of breast cancer, and although she had a mastectomy there may still be some breast tissue in her body for example on the chest wall. Of course it is important to note that by removing the vast majority of her breast tissue, she greatly reduced her breast cancer risk.

Figure 1. Angelina Jolie has made public her difficult decisions to minimize her risk of breast and ovarian cancer which is elevated by her BRCA1 mutation (Credit Luke MacGregor/Reuters via The New York Times).