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Angelina Jolie’s Brave Example – and the Other Side of the Story

But Will Angelina Jolie’s Message
Prove Misdirected 

Angelina jolie

Film actress and director Angelina Jolie penned a brave op-ed in today’s The New York Times  revealing her decision to complete a double mastectomy to prevent breast cancer that took her mother at an early age.

She made what had to be an arduous choice based on the BRCA1 gene she inherited that left her with an estimated 87% risk of developing breast cancer – a far higher risk than over 99% of women face.

This is a deeply personal choice all women with this inherited risk for both breast and ovarian cancer must make and no one, certainly not those of us spared this risk, has any right to second-guess them.  Angelina Jolie’s decision was made easier, it seems, by the presence of six young children she wants to protect and parent into adulthood and a supportive husband. Not everyone facing these choices is so blessed – nor do they have Angelina Jolie’s resources to assure optimal treatment and recovery.

I’m not much on celebrity but it’s hard not to be inspired by her story – and by her decision to share it as inspiration for others. My fear, however, is that more women will assume if it’s good enough for Angelina Jolie, then it’s good enough for them. For those who’ve inherited this gene that so dramatically increases their risk, this may be the wisest course of action.

But only a fraction of 1% of women have either the BRCA1 or BRCA2 gene, so it’s not especially rational for loads of women to now be asking for the expensive screening test required to confirm it. Sarah Kliff does a nice job outlining the issues about this in today’s WonkBlog at The Washington Post.

Don’t Get Scalpel-Happy

There’s good reason to fear, however, that many women will now rush to follow in Angelina Jolie’s footsteps – and not just because of our celebrity-obsessed culture.  There’s already good evidence that even women without the BRCA family of genes who’ve been diagnosed with the earliest possible sign of potential breast cancer – calcium deposits in breast tissue called ductal carcinoma in situ (DCIS) – are likewise choosing double mastectomies as preventive measures.

These women are closer to the opposite end of the risk spectrum from Angelina Jolie. There’s not even consensus that DCIS is cancerous, but rather a pre-cancerous condition that may or may not develop into cancer over time.

Still, nothing strikes fear in our hearts like the word “cancer” – so it’s not surprising that so many of us may overreact when presented with even the prospect that it may be coming our way. Men do the same when they insist on a radical prostatectomy or other prostate treatment when even their physicians may be urging a more cautious approach.

What often gets lost in the panic surrounding these choices is the downsides of these aggressive medical interventions – often more aggressive than is truly needed. In our quest for an “instant fix” with our healthcare choices, we often end up with the fabled unintended consequences. This is why I decided to write this posit – to focus just a bit, and I guarantee with none of the celebrity attention Ms. Jolie has deservedly received, on…

The  “Other Side of the Story”

Angelina Jolie’s announcement interestingly coincides with this week’s report that post-mastectomy pain persists for an estimated third of women who undergo this highly invasive surgery for up to ten years. The default treatment for chronic pain has become opioid medications like Percocet, Vicodin, and Oxycontin – all of which pose substantial risk of harm with chronic long-term use, including the potential spread of tumors (see “Medical Marijuana vs. Prescription Opioids – Misplaced Perceptions and Priorities“).

So putting more and more post-mastectomy patients on opioids for chronic pain control may have the ironic effect of spreading tumors and negating the expected preventive value of their mastectomies.

There are other consequences of chronic dependence on these potent opiates. The FDA just approved another drug to help counter their effects – this one for the constipation opioids routinely cause due to their adverse gastrointestinal effects. The account at MedPage Today summarized these as follows:

“Constipation is a common adverse event with opioid treatment as opioid binding to peripheral opioid receptors in the gastrointestinal (GI) tract can result in electrolyte absorption and decreased small intestinal fluid, as well as abnormal gastrointestinal motility.”

This may not sound like such a big deal, but it underscores the impact these powerful drugs have on your gut’s sensitive microbiota – the friendly and not-so-friendly bacteria and other micro-organisms (sometimes called flora) that populate your body, largely in your gut (small and large intestine, including your colon).

Which gives me a segue to another over-used class of medications that also do a job on your gut microbiota…

Antibiotic Overuse

Antibiotics have been over-prescribed for so long in America that it’s no longer a secret. And another story this week points to how common it is not just in hospitals, but in doctors’ offices and other outpatient settings as well – where an estimated half or more of prescribed antibiotics are useless and counter-productive. They’re counter-productive because they seriously disrupt your gut microbiota, killing the friendly gut bacteria you need and empowering the nasty ones that remain to wreak more inflammatory damage.

One of the unintended consequences here is increased risk for another deadly cancer – colon cancer. Combined with low-carbohydrate diets (Atkins, South Beach, Paleo) and a food supply of packaged grains largely stripped of protective fiber, these combine into a “perfect storm” for an epidemic of colon cancer.

Consider Your High Risk
for Medical Errors

Opioids and antibiotics are only two classes of medications that are misprescribed with abandon across America. There’s a much longer list, I promise, but I won’t bore you with the details right now (read Our Healthcare Sucks if you have any doubts).

Yet most patients are blissfully unaware of the hidden risks of this medical overtreatment. Our default mindset remains one of maximum medical intervention as if there were no downside.

Yet more Americans die every year from medical mistakes than from breast, prostate and colon cancer combined.

So if you have a known genetic risk that puts you at increased risk for a disease that may shorten your life, by all means explore all the options available to you.

But whether you have such an elevated risk or not, make sure you factor into your analysis the risks of medical mistakes – from your initial diagnosis (see “Medical Errors Start With Misdiagnoses“) to treatment to follow-up – that may prove worse than the condition you’re afraid you might have.

And don’t ever make a medical decision based on what a celebrity has chosen to do – or your next door neighbor, for that matter. They’re not you.

Do your own homework, assess the risks of agreeing to a medical intervention and not – because the risks cut both ways.

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