Skip to main content

What Angelina Jolie forgot to mention

By H. Gilbert Welch, Special to CNN
updated 10:25 AM EDT, Sat May 18, 2013
Angelina Jolie has several reasons to smile on her 39th birthday Wednesday, June 4. Her latest movie, "Maleficent," is No. 1 at the box office, <a href='http://www.nytimes.com/2013/05/14/opinion/my-medical-choice.html' target='_blank'>she's in good health following her double mastectomy, </a>and she also happens to be engaged to Brad Pitt, with whom she's raising six kids. While she's now known for her humanitarian works and action movies, Jolie has been in the spotlight since she was a child. Here's a look at her life. Angelina Jolie has several reasons to smile on her 39th birthday Wednesday, June 4. Her latest movie, "Maleficent," is No. 1 at the box office, she's in good health following her double mastectomy, and she also happens to be engaged to Brad Pitt, with whom she's raising six kids. While she's now known for her humanitarian works and action movies, Jolie has been in the spotlight since she was a child. Here's a look at her life.
HIDE CAPTION
Photos: Life of Angelina Jolie
Life of Angelina Jolie
Life of Angelina Jolie
Life of Angelina Jolie
Life of Angelina Jolie
Life of Angelina Jolie
Life of Angelina Jolie
Life of Angelina Jolie
Life of Angelina Jolie
Life of Angelina Jolie
Life of Angelina Jolie
Life of Angelina Jolie
Life of Angelina Jolie
Life of Angelina Jolie
Life of Angelina Jolie
Life of Angelina Jolie
Life of Angelina Jolie
Life of Angelina Jolie
Life of Angelina Jolie
Life of Angelina Jolie
Life of Angelina Jolie
Photos: Life of Angelina Jolie
Life of Angelina Jolie
Life of Angelina Jolie
<<
<
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
>
>>
STORY HIGHLIGHTS
  • Professor of medicine Gil Welch surprised by huge reaction to Angelina Jolie's op-ed
  • Welch fears women might wonder if they, too, should have preventive mastectomies
  • Welch: But 99% of women do not carry the BRCA1 mutation that raises the risk of breast cancer
  • He says women should look at family history before getting tested for the mutation

Editor's note: H. Gilbert Welch is a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice and a co-author of "Overdiagnosed: Making People Sick in the Pursuit of Health."

(CNN) -- I first saw the headline early Tuesday on Real Clear Politics, a political news site where I generally start my morning. It's not where I expect to see a story on breast cancer.

Then I checked my e-mail messages -- they all seemed to be about Angelina Jolie's op-ed. Students in my undergraduate class wanted to discuss it in our next session. Colleagues expressed concern and wondered what the right response was. People I don't even know sent e-mails.

One, from a research fellow at the International Agency for Research on Cancer, nicely summed up the general concern: "I fear that this disclosure will motivate other women to undergo preventive mastectomy, even though they do not need it."

Wow. Maybe I should read it.

H. Gilbert Welch
H. Gilbert Welch

I did. I found it to be a moving story and understood her choice. What I couldn't understand initially was the concern expressed by others.

As the day wore on, the story dominated the news. I didn't fully appreciate how much Ms. Jolie is admired and respected and had neglected to consider just how powerful a celebrity personal anecdote could be.

If American women saw themselves in Angelina Jolie -- then that would be a problem. Because the logical next question is: Should I get a preventive mastectomy?

Then I realized something was missing in her piece; something that should have been printed in big black letters:

NOTE: This story is not relevant to more than 99% of American women.

Angelina Jolie reveals double mastectomy
CNN anchor: I have breast cancer
Support pours in for Angelina Jolie

Why? Because more 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.

A few weeks ago, in a New York Times Magazine piece, Peggy Orenstein related her first instinct when facing breast cancer recurrence: take the other breast too. Her oncologist responded with a simple question: "Would an average woman cut off her breasts?"

I hope not.

But there is a second question for women raised by Ms. Jolie's piece: Should I be tested for BRCA1?

She seems to believe the answer is yes, pointing to the half-million women who die from breast cancer worldwide each year. But she neglects to point out that 90% of these deaths have nothing to do with the BRCA1 mutation. That's because most women don't have the mutation and because most breast cancer is sporadic.

Opinion: Jolie's choice: Risks and benefits

The few women who are likely to have the mutation are also likely to know they may have it based on the oldest genetic test of all: a strong family history of cancer.

Population-wide screening raises complex issues. We would want to know more about how often the test is wrong, particularly how often the test is falsely positive. That's important because women falsely diagnosed as a mutation carrier might undergo prophylactic mastectomy unnecessarily. Then there are the psychological effects, not only for the patient but also for her siblings and offspring.

We'd also need to know more about what a BRCA1 mutation means in the absence of family history. Ms. Jolie's mother died of ovarian cancer at age 56. I'm no geneticist, but I can guess that puts her at higher risk -- both for having the mutation and for developing a bad cancer.

And we'd certainly want an answer to the question: Must the test cost so much?

There's no one right choice for a woman in Angelina Jolie's position, but she may well have made the right choice for her. Luckily it is a choice most women don't have to face.

Follow us on Twitter @CNNOpinion.

Join us on Facebook/CNNOpinion.

The opinions expressed in this commentary are solely those of H. Gilbert Welch.

ADVERTISEMENT
Part of complete coverage on
updated 12:11 PM EDT, Fri August 29, 2014
Leon Aron says the U.S. and Europe can help get Russia out of Ukraine by helping Ukraine win its just war, sharing defense technologies and intelligence
updated 1:24 PM EDT, Fri August 29, 2014
Timothy Stanley the report on widespread child abuse in a British town reveals an institutional betrayal by police, social services and politicians. Negligent officials must face justice
updated 9:06 PM EDT, Fri August 29, 2014
Peter Bergen and David Sterman say a new video of an American suicide bomber shows how Turkey's militant networks are key to jihadists' movement into Syria and Iraq. Turkey must stem the flow
updated 11:16 AM EDT, Thu August 28, 2014
Whitney Barkley says many for-profit colleges deceive students, charge exorbitant tuitions and make false promises
updated 10:34 AM EDT, Fri August 29, 2014
Mark O'Mara says the time has come to decide whether we really want police empowered to shoot those they believe are 'fleeing felons'
updated 10:32 AM EDT, Thu August 28, 2014
Bill Frelick says a tool of rights workers is 'naming and shaming,' ensuring accountability for human rights crimes in conflicts. But what if wrongdoers know no shame?
updated 10:43 PM EDT, Thu August 28, 2014
Jay Parini says, no, a little girl shouldn't fire an Uzi, but none of should have easy access to guns: The Second Amendment was not written to give us such a 'right,' no matter what the NRA says
updated 1:22 PM EDT, Sat August 30, 2014
Terra Ziporyn Snider says many adolescents suffer chronic sleep deprivation, which can indeed lead to safety problems. Would starting school an hour later be so wrong?
updated 9:30 AM EDT, Fri August 29, 2014
Peggy Drexler says after all the celebrity divorces, it's tempting to ask the question. But there are still considerable benefits to getting hitched
updated 2:49 PM EDT, Fri August 29, 2014
The death of Douglas McAuthur McCain, the first American killed fighting for ISIS, highlights the pull of Syria's war for Western jihadists, writes Peter Bergen.
updated 6:42 PM EDT, Tue August 26, 2014
Former ambassador to Syria Robert Ford says the West should be helping moderates in the Syrian armed opposition end the al-Assad regime and form a government to focus on driving ISIS out
updated 9:21 AM EDT, Wed August 27, 2014
Ruben Navarrette says a great country does not deport thousands of vulnerable, unaccompanied minors who fled in fear for their lives
updated 9:19 AM EDT, Wed August 27, 2014
Robert McIntyre says Congress is the culprit for letting Burger King pay lower taxes after merging with Tim Hortons.
updated 7:35 PM EDT, Tue August 26, 2014
Wesley Clark says the U.S. can offer support to its Islamic friends in the region most threatened by ISIS, but it can't fight their war
updated 7:26 AM EDT, Wed August 27, 2014
Jeff Yang says the tech sector's diversity numbers are embarrassing and the big players need to do more.
updated 4:53 PM EDT, Tue August 26, 2014
America's painful struggle with racism has often brought great satisfaction to the country's rivals, critics, and foes. The killing of Michael Brown and its tumultuous aftermath has been a bonanza.
updated 4:19 PM EDT, Tue August 26, 2014
Ed Bark says in this Emmy year, broadcasters CBS, ABC and PBS can all say they matched or exceeded HBO. These days that's no small feat
updated 3:19 PM EDT, Tue August 26, 2014
Rick Martin says the death of Robin Williams brought back memories of his own battle facing down depression as a young man
updated 11:58 AM EDT, Tue August 26, 2014
David Perry asks: What's the best way for police officers to handle people with psychiatric disabilities?
updated 3:50 PM EDT, Mon August 25, 2014
Julian Zelizer says it's not crazy to think Mitt Romney would be able to end up at the top of the GOP ticket in 2016
updated 4:52 PM EDT, Mon August 25, 2014
Roxanne Jones and her girlfriends would cheer from the sidelines for the boys playing Little League. But they really wanted to play. Now Mo'ne Davis shows the world that girls really can throw.
updated 12:29 PM EDT, Mon August 25, 2014
Peter Bergen and Emily Schneider say a YouTube video apparently posted by ISIS seems to show that the group has a surveillance drone, highlighting a new reality: Terrorist groups have technology once only used by states
updated 5:04 PM EDT, Mon August 25, 2014
Kimberly Norwood is a black mom who lives in an affluent neighborhood not far from Ferguson, but she has the same fears for her children as people in that troubled town do
updated 5:45 PM EDT, Fri August 22, 2014
It apparently has worked for France, say Peter Bergen and Emily Schneider, but carries uncomfortable risks. When it comes to kidnappings, nations face grim options.
updated 1:27 PM EDT, Tue August 26, 2014
John Bare says the Ice Bucket Challenge signals a new kind of activism and peer-to-peer fund-raising.
updated 8:31 AM EDT, Fri August 22, 2014
James Dawes says calling ISIS evil over and over again could very well make it harder to stop them.
updated 9:05 PM EDT, Sat August 23, 2014
As the inquiry into the shooting of Michael Brown continues, critics question the prosecutor's impartiality.
updated 6:47 PM EDT, Fri August 22, 2014
Newt Gingrich says it's troubling that a vicious group like ISIS can recruit so many young men from Britain.
updated 10:50 AM EDT, Thu August 21, 2014
David Weinberger says Twitter and other social networks have been vested with a responsibility, and a trust, they did not ask for.
updated 7:03 AM EDT, Fri August 22, 2014
John Inazu says the slogan "We are Ferguson" is meant to express empathy and solidarity. It's not true: Not all of us live in those circumstances. But we all made them.
updated 8:23 AM EDT, Fri August 22, 2014
Retired Lt. Gen. Mark Hertling says he learned that the territory ISIS wants to control is amazingly complex.
updated 3:51 PM EDT, Wed August 20, 2014
Cerue Garlo says Liberia is desperate for help amid a Ebola outbreak that has touched every aspect of life.
updated 1:42 PM EDT, Thu August 21, 2014
Eric Liu says Republicans who want to restrict voting may win now, but the party will suffer in the long term.
updated 11:38 AM EDT, Thu August 21, 2014
Jay Parini: Jesus, Pope and now researchers agree: Wealth decreases our ability to sympathize with the poor.
updated 8:00 AM EDT, Thu August 21, 2014
Judy Melinek offers a medical examiner's perspective on what happens when police kill people like Michael Brown.
updated 6:03 PM EDT, Tue August 19, 2014
It used to be billy clubs, fire hoses and snarling German shepherds. Now it's armored personnel carriers and flash-bang grenades, writes Kara Dansky.
updated 1:27 PM EDT, Wed August 20, 2014
Maria Haberfeld: People who are unfamiliar with police work can reasonably ask, why was an unarmed man shot so many times, and why was deadly force used at all?
ADVERTISEMENT
ADVERTISEMENT
ADVERTISEMENT
ADVERTISEMENT