Angelina Jolie... Overtreatment? (Philosophical Questions)

So… I don’t want to open a giant can of worms, but I do have questions regarding diagnosis and treatment for prostate cancer, with particular emphasis on men who biopsy G6 in their 40's. In light of the recent debates here about over-diagnosis and over-treatment of prostate cancer, I’m wondering how Angelina Jolie would be seen here?

I find myself in a strange conundrum because I disagree with her having treatment for breast cancer since she hadn’t actually developed it. Nevertheless, I don’t have a problem with her making a decision to do what whe did. I also think doctors have to exercise restraint at times, so I’m also torn about one choosing to do it, but I don’t find it necessarily wrong of them to provide “service.”
This is already turning out to be a strange post.

What I’m interested in determining is if people think she is “hysterical” for making the decision that she did. Or whether you feel she has the right to pursue the course she chooses whatever the reasoning. Or whether you feel a doctor should refuse such a request or, at least, counsel against it.

To me her decision seems a little reactionary. If I had to put her “disease” on a spectrum of need overlaying our own disease, she would be comparable to a man with a family history of PCa, with at least a father who died miserably as a result of it (because her mother evidently suffered with breast cancer). But she had no symptoms, no inclination that she had BCa, and no positive tests or biopsies. For all intents and purposes she was disease free. She did have genetic testing that said she had a 9X% chance of developing BCa. So, imo, she would be equivalent to a male with a slightly elevated PSA, but no positive biopsies, etc.

We’ve been taught as patients that one treats early and, hopefully, conclusively when encountering a health problem. When is too early? When is just the right time? And when is it too late? When is treatment appropriate? What level of treatment is appropriate? And at what stage of disease? How or when does someone become “overtreated?” These seem insurmountable to me. For me it boiled down to, “What’s right for me?”

I wrestled with posting this question. I’m sure there will be differences of opinion.

I have couple requests, as a G6 guy who rarely gets truly upset by comments on this message board…
1. Keep the discussion civil and from the perspective that this is an early-mid 40’s “patient,”
2. Keep it focused on the G6, T1-2b staging level and earlier, like elevated PSA, family history, and
3. Presume that this hypothetical guy seeking resolution to his disease is thoughtful and level-headed in his decision making process. (In other words, the, so called, “hysteria” of a cancer diagnosis… or potential cancer diagnosis, has passed.)

What I’m interested in knowing is if a guy came here tomorrow and his name was Angelo Jolie, what would you say to him about his decision to have surgery or radiation to eliminate his chances of developing PCa? And a thing to consider as well is the relative youth of the hypothetical person. I don’t know, I’m really uncertain about the meaning of “over-treatment” and “over-diagnosis.” I don’t want guideline type answers tho. I want examples, hypotheticals, I guess.

I’m comfortable with my own treatment path. This is not where I want to go with this discussion. Surgery about 16 months after two odd DRE’s and an two elevated PSAs was right for me. I’m estatic about my personal outcome. I’m not second guessing myself. I’m more interested in the philosophical discussion of the “right time and method on treatment.” And how Angelina’s decision to do what she did BEFORE she had disease is viewed here.

Gee whiz. I hope you get what I’m talking about…

"So, imo, she would be equivalent to a male with a slightly elevated PSA, but no positive biopsies, etc."

From memory, a man with an elevated PSA as you describe above has about a 25% chance of getting PCa. AJ has an 88% chance of getting breast and ovarian cancer. Ovarian cancer poses few symptoms, and kills on average much faster than PCA. Breast cancer is easier to detect and has lower mortality rates than Ovarian cancer - however my personal experience with this was a colleague I worked with in my twenties when she was 22. Both her sister died under the age of 30 from breast cancer which also killed her mother in her 30s. At the time there was no test but with her history she knew she was likely to get it and had the double masectomy. In her position I would have done exactly the same thing. I last heard from Rachel about 8 years later, she was married with two children and no breast cancer.

I think it is not an easy decision and not a decision for everyone but with the odds I probably would have done what she did.

Regards,
AN

I was glad that my biopsy was 4+3. If it were a 6, that would have made my decision much harder, and I would be wrestling with these very question.

I like this post.

AJ did have some bad biomarkers. She had the BRCA1 gene but historically that does not predict with certainty that she would ever get breast cancer. Christina Applegate also went the radical rout because of the same reasons.

Still the discussion of prophylactic procedures in prostate cancer have been discussed for years. And some men have had advanced prostatitis and because they also have family history with prostate cancer they elected to have the preventive procedure knowing it would also put an end to the debilitating prostatitis.

Can we stratify men as well as BRCA1/2 women can be?

Here are a few articles on how it might apply to men:
prostatecancerinfolink.net/?s=brca1

Tony

As a woman, I understand her decision completely, particularly after losing a friend to non hodgkins lymphoma. The need to be here for our children is a strong one.

If a guy named Angelo Jolie tested brca1 or brca2 I would say that removing the prostate before there are signs of cancer is not necessary because there is the psa test to help give clues that something is going on with the prostate...while not perfect, it is at least a routine test given and it will raise a concern to a doctor.

For us ladies, we don't get a blood test to help us know whether something is wrong in our body. All we get is a little feel-up by the doctor once a year. That's it. Ovarian cancer...same thing--no real blood test to give as part of routine preventive care, and nothing but a cursory digital exam.

So I can really empathize with her decision to get prophylactic mastectomy and oophorectomy. If it was a man with those genes, I would expect more frequent psa readings and whatever else can be done to increase the odds of catching it as soon as possible.

I think her decision was absolutely appropriate and needed in her situation, it was good pro-active move on her part, and showed great courage. My hat is off to her, and to Christina Applegate in her situation as well.

I fully support all our BC sisters out there without question.

david in sc

i'm so sick of cancer

Me? I believe in people deciding on the treatment(s) they feel they need.

Susan - i read a thread on a cancer forum about this same topic the other day.

One of the guys there who had a wife with breast cancer compared BC and PCa insofar as the intimacy between him and his wife changed once she got and treated BC with a mastectomy.

I think the genetic test costs about $3K.

I'm sorry you're so anxious about your upcoming tests, I hope everything goes well as I'm sure it will.

those are my exact sentiments as well, TA

Dude, apples and oranges. Gleason grading describes histologically how a cell looks, G6 still looking pretty close to what normal prostate cells should look like under a microscope. BRCA is genetic mutation that predisposes one to cancer, and from what I understand, an aggressive cancer, too. But, I get your point, and it is an interesting discussion.

I thought it was a brave decision, but pretty much unavailable for most commoners because of the lack of awareness (increased since AJ letter) and cost, even in the US, muchless the rest of the world. This type genetic testing is OK to do if you are ready to face the results and know what to do with them. If you do testing and get a result that you are likely to get lung or brain cancer, what preventetive measures are there?

Thanks for all the replies.

Susan R, I'm 43 and adopted too. My GP has done DRE's every year since I turned 30 and before that, thru my 20's, nearly every year. I'm glad to have someone as thorough. It seems you do too. I'm sure all will be fine once again with your upcoming exam.

So does everyone's opinion stay the same without the genetic test? Change the situation she was in a bit. Say there was no such genetic test available... she's working strictly from family history or there was a non-cancerous lump that was discovered that prompted this decision to do what she did. Does that change your feelings at all? Perhaps that puts us closer to the realm of what I was considering initially.

Hi An, that is a good solution in Australia. I recently read the article from the country where I was born (centraleast Europe) and only about 30 women took part in this testing last year (BRCA), and they had to wait for results from 6 months to a year! This is because this testing is only done as part of research and not commercially available. What about countries in Africa, South America, Asia, etc...? but this may be embarking on a different topic...

Regarding brain, etc, I mean breasts and prostate do not have any vital role in human organism, although their removal is a major surgery with possible complications. However, removing ovaries would put a woman in menopause (similar to HT in men) and put her at a greater risk of heart disease, osteoporosis, etc. If Angelina plans to do this at 35, if would, for sure impact her QOL, I think this is why she chose to deal with breast issue first.