A star's giant leap for womankind
If this was Angelina Jolie's master plan to divert attention from her upper thigh, which she flashed to worldwide acclaim last year at the Oscars, it was an extraordinarily dramatic one. This week, in an article for the New York Times, Jolie revealed that, to avoid developing breast cancer, she had undergone a double mastectomy.
As a result, the disease that took Jolie's mother, Marcheline Bertrand, at the age of 56 after a decade of illness would no longer cast a shadow over the 37-year-old actress and her family. But Jolie's sentiments were about more than just survival.
The power of what she wrote lies in the fact that she is feted for her looks and sexual allure - and that, although a lesser mortal may feel desexualised by the experience of losing her breasts, this icon of beauty apparently does not: "On a personal note, I do not feel any less of a woman. I feel empowered that I made a strong choice that in no way diminishes my femininity."
Along with reassuring us on the state of her body and the ongoing health of the Brangelina partnership, she does something surprising: she champions science as a means for women to shape their own medical destiny. And while she's at it, she takes a much-needed swipe at the genetic testing industry for pricing breast cancer tests beyond the reach of most women.
Certainly, Jolie's account of how and why she came to lose her breasts constitutes a milestone in the public acceptance of what has tended to be seen as a rather extreme act of self-preservation.
"The article is a very brave thing for her to have done, especially because it looks as though she could have got away without saying anything," said Professor Alan Ashworth, chief executive of the Institute of Cancer Research in the UK and a member of the research team that discovered BRCA2 - one of the two key genes that, when mutated, contribute to inherited breast and ovarian cancers (Jolie carries a mutation on the other gene, BRCA1).
"The fact is that with that mutation she is at a very significant risk of breast cancer," said Ashworth . "Women in her position are routinely offered the option of having their breasts and ovaries removed."
Jolie had not only normalised the idea of prophylactic surgery, he said, but flagged the need to make testing more affordable and accessible.
In life's genetic lottery, Jolie has so far been an enviable winner. Beautiful, rich and talented, she has a film star lover and six children, plus a creditable record as a UN special envoy for refugee issues. But her mother's battle with breast cancer, which started when she was only in her forties, must have led Jolie to suspect the possibility of a genetic imperfection.
The uncommon mutation in her BRCA1 gene could have been inherited from either her mother or her father, actor Jon Voight. A family history of breast cancer, however, does not always mean that the smoking gun is a genetic one - at least 95% of breast cancers are not associated with any specific genetic mutation. Instead, they are thought to result from a complex interplay of milder genetic risks and lifestyle factors such as smoking and delayed motherhood.
But those who do test positive for either a BRCA1 or BRCA2 mutation - having both is virtually unheard of - live with a 50% to 80% chance of developing breast cancer in their lifetime. This is the point at which a bilateral, or double, mastectomy comes on to the radar, as well as ovary removal.
Whereas breasts are relatively easy to screen for lumps, ovaries are not. Given that ovaries produce oestrogen and oestrogen is the hormone associated with ovarian and breast cancers, some women choose to cut their risk by undergoing an oophorectomy, (removal of an ovary or ovaries), coupled with ongoing breast surveillance.
Despite these choices, some women still opt for breast removal. Dick Rainsbury, president of the Association of Breast Surgery in the UK and director of the Breast Unit at Hampshire Hospitals NHS Foundation Trust, said it was mostly younger women who went down this route: "They've got the greatest risk and the longest life expectancy. Older, post-menopausal women have got through most of their life without developing breast cancer and tend to be quite pragmatic about their chances. Also, it's generally easier to look for cancers in older breasts."
Ovary removal is not ideal for younger women who might one day want to become mothers.
Although bilateral mastectomy is still relatively unusual as a preventive measure, Rainsbury said he had seen a significant escalation of interest. The growing popularity may also be because of the improvement of surgical techniques, which means that a woman no longer has to trade off her appearance for her peace of mind.
"If done well, it's really hard to tell the difference," he said. The breast tissue can be extracted through an incision 5cm long, either around the curve of the aureola (the coloured area around the nipple) or underneath the breast.
Interestingly, Jolie opted for the technique that is most like a standard boob job. First, she underwent a procedure to save her nipples - after first checking that they were disease-free - and then had expanders put in to replace the removed breast tissue.
But there are two modern techniques that result in a more natural look. The first is autologous flap reconstruction, which involves replacing the removed breast tissue with the patient's own tummy tissue.
Essentially, it is a tummy tuck and breast reconstruction rolled into one: "This is the most lifelike option because it uses your own tissue. Your breasts age with you, and when you lose or gain weight your breasts lose and gain with you."
The other technique borrows muscle, skin and subcutaneous fat from the back. This tissue can be supplemented with an implant if need be.
Perhaps the biggest public service that Jolie has done, though, is to highlight the stranglehold that one company continues to exert over the domain of breast cancer testing. As she writes: "The cost of testing for BRCA1 and BRCA2, at more than $3000 in the US, remains an obstacle for many women." The patents are held by Myriad Genetics, a Utah-based company that owns and enforces the worldwide rights to genetic tests relating to BRCA1 and BRCA2.
Myriad's monopoly is being challenged in the US Supreme Court by, among others, the American Civil Liberties Union, which is against the increasing corporatisation of the human genome (about 20% of human genes are now subject to patents). That is a battle that Jolie, in her own way, may help to win. - ©The Daily Telegraph, London