May 23, 2013

YOU'RE NO ANGELINA:

What Angelina Jolie forgot to mention (H. Gilbert Welch, 5/18/13, CNN)

[M]ore than 99% of women do not have the BRCA1 mutation -- or the BRCA2 mutation, for that matter.

Let's be clear, the BRCA1 mutation is a bad thing. Although I might quibble with the exact numbers in the piece, the big picture is this: the mutation increases the risk of developing breast cancer about five fold and increases the risk of ovarian cancer more than 10 fold.

It is a powerful risk factor for these cancers -- almost as powerful as cigarette smoking is for lung cancer.

When people are at very high risk for something bad to happen, preventive interventions are more likely to be a good deal; that is, the benefits are likely to exceed the harms. I'm not saying that prophylactic mastectomy is the right choice for a woman with BRCA1, simply that it is a reasonable one.

When people are at average risk, the deal changes. The opportunity for benefit is less, simply because the bad event is less likely to happen. But the harms of preventive intervention remain roughly the same.

It is a fundamental precept of medicine -- one I hammer home with undergraduates (future patients) and medical students (future doctors): Patients with severe abnormalities stand to gain more from intervention than patients with mild ones. Patients with mild abnormalities are more likely to experience net harm from intervention, simply because they have less opportunity to benefit.

The vast majority of women don't have the BRCA1 mutation. They are at average risk for breast cancer. They are not Angelina Jolie. They should not have a preventive mastectomy.

Posted by at May 23, 2013 4:02 PM
  

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