
My Medical Choice - tbassetto
http://www.nytimes.com/2013/05/14/opinion/my-medical-choice.html
======
Swizec
I find it fascinating that just over a hundred years ago proactive teeth
removal was a standard practice. Women would get all their teeth removed to
save money for the prospective husband. And left untreated for too long,
rotten teeth will definitely kill you through infection.

These days, women are getting proactive mastectomies, not so much because of
the costs involved in treatment, but because cancer is a much scarier disease
than teeth rot. At least to us. To us proactively removing your teeth is a bad
joke.

In 100 to 150 years, will people think about a proactive mastectomy as a bad
joke? I sure hope so.

~~~
theorique
_I find it fascinating that just over a hundred years ago proactive teeth
removal was a standard practice._

What would people eat then? Smoothies, cream of wheat?

~~~
john_w_t_b
They used false teeth.

~~~
theorique
Hmm, I guess that makes sense. Seems so primitive compared to modern dentistry
though.

------
Evgeny
_I am fortunate to have a partner, Brad Pitt_

Took me a few seconds to process and understand who the author is.

~~~
rythie
I don't get why they don't make a bigger thing of who the author is on this
one.

~~~
meatsock
she's credited in the byline

~~~
rythie
Yes - but you miss that because it's not normally important - i.e. it's no one
you've heard of.

~~~
disputin
Breast cancer is more important in "someone important, like an actor"?

~~~
jergosh
It's a braver decision from someone who depends on their looks for livelihood.
Also creates a mindset "if she could do it, then so could I"

~~~
disputin
I'd expect it's less brave for someone from an industry and social circles
comfortable with implants, injections scalpels, etc, and with a bit more than
a "livelihood" to ease the experience. The experience would surely be more
foreign to the average woman, requiring more bravery. Angelina isn't dependent
on the look of her breasts for her "livelihood". 87% risk is a no brainer.

~~~
jergosh
It's easy to talk about 'no-brainers' in the abstract. A different story if
it's your own favourite bit.

------
michh
Preventive medicine like this saves lives and money. But try convincing the
pencil pushers. Looks like in both privatized and nationalized healthcare,
they are often only willing to pay when there's a disease to diagnose. Not
when there's an 80% chance you'll get it later when it's much harder and
expensive to cure. Unless you have Jolie money and can simply afford to pay
for it yourself.

~~~
yummyfajitas
_Preventive medicine like this saves lives and money._

Sometimes it does, sometimes it doesn't. Lots of preventative medicine doesn't
save either lives or money - mammograms below age 50 are a good example. The
increased risk of infection from doing a biopsy on a non-cancerous mass (and
similar complications) outweigh the rare early breast cancer cases prevented.

[http://www.uspreventiveservicestaskforce.org/uspstf/uspsbrca...](http://www.uspreventiveservicestaskforce.org/uspstf/uspsbrca.htm)

[http://www.bloomberg.com/news/2012-07-31/in-mammogram-
debate...](http://www.bloomberg.com/news/2012-07-31/in-mammogram-debate-
politics-trounces-science.html)

I don't know the specific details of this case. Maybe she reduced her risk, or
maybe she traded a 5/1000 risk of cancer for a 6/1000 risk of infection.

But this "preventative medicine saves lives and money" meme needs to die.
Sometimes it's worthwhile, sometimes it's not. Numbers >> political memes.

~~~
kyro
Needs to die? What are you talking about? Obviously administering tests that
haven't been shown to be effective prophylactically and can even cause harm to
a given population is a stupid idea. That's why we do research and weigh
benefits/risks. That's like saying antibiotics need to die because many times
they don't work and can cause resistant strains, when the problem is that
physicians often administer them incorrectly.

Appropriate preventative medicine supported by research and numbers is so, so
important.

~~~
jasallen
It's more akin to saying "Antibiotics for every cold and allergy needs to
die", which, is true.

The other poster said the meme needs to die, not _all_ preventative medicine.

------
rms
Note that the BRCA test costs $3k when purchased through a physician, but
23andme violates the patents and tests for BRCA for $99. <http://23andme.com>

~~~
jurassic
Have you done this? I'm interested in knowing my genetic risk factors, but I'm
afraid of how I would handle it if there was something really bad and
unexpected.

~~~
berberous
I have done 23andMe and had my full genome sequenced. Unfortunately, we are
still in the early stages of understanding our genome and there is often
little of medical importance revealed.

The most significant of the "something really bad and unexpected" are the risk
factors for Alzheimer's and Breast Cancer. I believe that there are certain
markers for both those diseases which could reveal that you have a much higher
lifetime risk (for some cases of breast cancer, >50%), which is obviously
scary. Don't quote me on this, but I believe in both situations you are very
likely to have had some family history in these diseases, so it should not be
a total surprise. And if you have a family history of breast cancer, you
should be getting Myriad's full BRCA test (see my other post). I would
probably look into a clinical test for Alzheimers too if I thought I was at
risk.

There are a few other diseases that also have big impact (>50% lifetime risk),
but they are rarer, and I'm not sure if there are any where you would have had
no family or personal history to clue you in on the possibility.

The vast majority of the diseases 23andMe reports on give you very little
actionable data. For example, it might say I have a 2x risk of prostate
cancer, from a background risk of 2% chance to a personalized 4% chance. I
view that as pretty unhelpful. Furthermore, it's based on SNP-associations
currently known. It's possible, I have another SNP that's associated with a
.25x risk, and therefore I actually have only 1% chance overall, i.e. half the
general population's risk.

23andMe can be useful for other reasons. For example, it will tell you if you
are a recessive carrier of certain diseases, which is helpful if and when you
decide to have children. It's also fun, has ancestry info, etc.

~~~
Gmo
Shameless plug for a friend of mine, but <http://www.snpedia.com/> and
<http://promethease.com> can help you further in your analysis (if you don't
already know those tools).

------
rdl
I assume a lot of women would want to wait until after they were done having
children (particularly since ovaries would also be removed). It might be a
harder choice between "mastectomy/oophorectomy and sterility" and "increased
risk of cancer" for a 22 year old.

Also surprised the patents on BRCA didn't come up in this article, just the
cost.

~~~
ssprang
On the other hand, given a genetic risk factor so potentially life threatening
that it warrants having body parts preemptively removed, you might think twice
before reproducing.

~~~
Osiris
That would certainly be a great way to prevent genetic disorders for future
generations, just disallow anyone with a pre-disposition from reproducing
and/or being born.

That seems like an odd way to look at reproduction. Would you rather like 50
years and die of cancer or not have lived at all?

It's one thing to make a decision when there's medical evidence during the
pregnancy that can be tested but when you're only talking about a statistical
risk that something may or may not occur...

~~~
ssprang
I was implying a personal decision to avoid becoming pregnant in the first
place. I guess if you want to knowingly risk passing genes that cause terrible
disease and suffering to all your descendants… yay freedom!? There are other
options if having kids is important to you.

------
gdonelli
At first I thought, this wasn't relevant to HN. But then I realized that A.
Jolie is hacker. She is trying to hack her life.

~~~
pervycreeper
><http://www.imdb.com/title/tt0113243/>

~~~
gdonelli
1995!

~~~
ISL
RISC is good.

------
irollboozers
Elizabeth Iorns, the CEO of Science Exchange (YC S11), is currently conducting
independent research to find a potential cure specifically for the BRCA
mutation.

([https://www.microryza.com/projects/can-we-prevent-the-
transm...](https://www.microryza.com/projects/can-we-prevent-the-transmission-
of-brca-mutations))

------
spullara
This is generally covered by insurance in the US, including the reconstructive
surgery.

[http://breastreconstructionnetwork.com/will-my-insurance-
com...](http://breastreconstructionnetwork.com/will-my-insurance-company-pay-
for-a-mastectomy-to-reduce-my-risk-of-breast-cancer/)

~~~
hispanic
Generally, maybe. My friend had this surgery recently and she had to fight
(her insurance company) for it.

------
davidrudder
My mother lost both breasts, her gallbladder and her fallopian tubes to 4
separate cancers. When they discovered the BRCA gene mutations, she was tested
and turned out positive. My sister tested positive and had proactive
masectomies and hysterectomies. I was tested as well, but came up negative for
the BRCA mutations ( _phew_ ). I'm male, but if I was positive it would have
meant changes for my daughter.

One advantage of the human genome project was that it lead to discoveries like
the BRCA mutations. Now, the women in my life could decide ahead of time to
prevent these cancers.

------
stevoski
Do any of my fellow HN readers know enough to say that Angelina Jolie
processed the available information of her extremely high risk of breast
cancer correctly? Is the mathematics logical?

Something I wondered is, that given that 1 in 3 American women will have
cancer sometime during their life, (and 1 in 5 will die from cancer), how much
has she improved things by reducing from 87% to 5% the chance of having one
specific cancer?

~~~
300bps
Wikipedia has a good summary of the risks:

<http://en.wikipedia.org/wiki/BRCA_mutation>

 _A 25-year-old woman with no mutation in her BRCA genes has an 84%
probability to reach at least the age of 70.[16] Of those not surviving, 11%
die from either breast or ovarian cancer, and 89% from other causes._

 _Compared to that, a woman with a high-risk BRCA1 mutation, if she had breast
cancer screening but no prophylactic medical or surgical intervention, would
have only 59% chance to reach age 70, twenty-five percentage points lower than
normal. Of those women not surviving, 26% would die of breast cancer, 46%
ovarian cancer, and 28% other causes.[16]_

 _Women with high-risk BRCA2 mutations, with screening but with no
prophylactic medical or surgical intervention, would have only 75% chance to
reach age 70, nine percentage points lower than normal. Of those not
surviving, 21% would die of breast cancer, 25% ovarian cancer and 54% other
causes.[16] The likelihood of surviving to at least age 70 can be improved by
several medical interventions, notably prophylactic mastectomy and
oophorectomy.[16]_

~~~
ttflee
But, given that she is a Hollywood celebrity? Does the likelihood varies on
this condition?

------
js2
See also <https://news.ycombinator.com/item?id=5607618> (discussion of "Our
Feel-Good War on Breast Cancer"). That article does not address women with a
BRCA mutation however.

------
juskrey
Google: "Angelina Jolie complies diet, which combines a high percentage of
carbohydrates and proteins with a low percentage of fat intake."

Meanwhile, in PubMed: "Women in the highest glucose quartile were 63% more
likely to develop breast cancer."

------
jergosh
Her going public about this has got a great potential to raise awareness and
make other women more likely to consider this course of action. The sad
reality is, however, most women won't be able to afford the reconstructive
surgery (or to have it done to the standard Angelina Jolie has).

~~~
irollboozers
I think more importantly it brings up the very real human implications of the
debate against patenting human genes, which has most recently been centered
around the BRCA gene.

[http://www.npr.org/blogs/health/2013/04/15/177035299/supreme...](http://www.npr.org/blogs/health/2013/04/15/177035299/supreme-
court-asks-can-human-genes-be-patented)

------
dannowatts
i think it's brave and commendable of ms. jolie to open up about something so
personal and difficult, using her fame and notoriety to help others who come
into similar situations.

much respect sent her way.

------
startupstella
I think this is a great example of how a celebrity can use star power to
impact the lives of other women. I only wish she had not done this in
secret...if there are tabloid reports of pregnancy and weight loss, why not on
such an important issue that can have an impact?

I also wish (for the first time ever) that she had introduced herself earlier
in the article. Just like many readers, I didn't realize this was Angelina
Jolie until very late in the article (which doesn't minimize her story, it
just puts it in a different context).

~~~
palimpsests
| I only wish she had not done this in secret.

Not done what? She published an account of her medical decisions in the NYT...
hardly secret.

------
Mz
I will add that breast cancer runs very heavily in my family. My sister has
had two mastectomies and four occurrences of breast cancer. My mother has had
two occurrences of breast cancer, one mastsctomy, one lumpectomy. I took care
of my sister after her first mastectomy. I know how severely and permanently
impaired my two workaholic relatives are. Angelina Jolie may be less impaired
than my relatives because she might not have had lymph nodes removed. But this
is major surgery and she is really downplaying that.

My sister likes to garden. She used to dig in the red Georgia clay with a pick
axe. These days, she can't even vacuum. Her arms are prone to swelling. She
does not have the strength she once had. Her life is far more limited than it
once was. For years, my mother owned two pathetic, falling apart bras.
Anything new with the eladtic still working made her arm numb and caused it to
swell. She cannot tolerate anything snug, so she also wears a hugely oversized
one piece bathing suit. They carry on and are not complainers. But the reality
is they are both very seriously and permanently impaired.

Having seen what my relatives have been through, I understand why Angelina
would make such a radical choice. I have done some rather extreme things as
well for health reasons. But I am disturbed by the way this is being glossed
over. I hope she remains satisfied with her choice. But with her fame and
beauty and social influence, I think she is being negligent and irresponsible
to make light of the consequences of this surgery. It may be a perfectly
reasonable thing to do, but it is not without consequence.

------
Mz
I have mixed feelings about seeing this. On the one hand, I do understand why
she would make such a choice and I am cool with her using her fame to try to
promote awareness and discussion. On the other, I am not happy with the way so
much of modern medicine mutilates people instead of making them genuinely
healthy and her example helps encourage people to feel that is okay.

------
Eva_Peron
Best of luck to Crash Override. You're the best!!

~~~
mrexroad
ahem, acid burn.

------
lostlogin
The quality of the surgery is important too. If a plastic surgeon does it they
tend to be less aggressive in scraping every last bit of tissue off before
reconstruction. Breast surgeons tend to be more aggressive. Source: breast
surgeon in the practice next door who I was discussing this with. Due to the
source there may be a bit of profession bias.

------
exit
is this on the front page of hn because jolie starred in hackers?

~~~
mysterywhiteboy
It is on the front page because enough readers of hacker news considered it
interesting and [hacker]newsworthy, and therefore up-voted it.

~~~
exit
yeah, and by extension i'm asking why enough readers of hn considered it
interesting.

~~~
prawn
Could be said that not enough people make health decisions based on risk.
Someone quite public has done exactly that.

------
EvilLook
And what do women without insurance, money, and BRCA mutations do?

------
Swisscoder
utterly pointless... By that logic some say we were born to the grave.

------
yason
You can run but you can't hide. Body is a 100% accurate signal of your
condition. She's messing with it to remove reception: it's like taping your
car's warning light black so that you won't have any problems.

~~~
outworlder
Erm, no.

She can't have breast cancer if she doesn't have any breasts anymore!

What she is doing is prevention. Like fixing the engine before the warning
light comes up.

~~~
bugschivers
Actually, she can, breast cells are not limited to the breasts, neither are
ovarian cells limited to the ovaries, hence the 5 - 10% remaining risk. Woman
who have this procedure cannot expect to never have to check for ovarian or
breast cancer again, it is not a 100% preventative.

