I am writing in response to an article you published in your issue dated July 2013 about Angelina Jolie and her risk of breast cancer. I was appalled to read that you are advocating against mastectomies as a preventative strategy for women at high-risk of breast cancer. The evidence you supply in the article is confusing and does not represent a balanced and evidence-based argument about the benefits of preventative surgery. I believe that the way you have structured the article aims to deter people from considering a mastectomy by misinterpreting evidence – and in some cases – completely ignoring the evidence. It is also clear that you have not understood Angelina Jolie’s breast cancer risk and as such have made claims irrelevant to her or other women carrying mutant BRCA genes. Below I have listed claims that I think are incorrect or have no bearing on the subject.
Confusing ‘family history’ with ‘genetic history’
You state that ‘most women with a family history of breast cancer will never get the disease’. There is no problem with this statement until later on in the paragraph you have written “For women with one close relative with breast cancer, the lifetime risk is 8 per cent, which increases to just 13.3 per cent for those like Angelina Jolie, with two close relatives who had the disease”. The problem here is that Angelina Jolie also carries a BRCA mutation which forms part of her genetic history. The reference you have cited (http://www.ncbi.nlm.nih.gov/pubmed/11705483) is not relevant to Angelina’s breast cancer risk as this study does not take into account the effects of BRCA mutations on breast cancer risk.
Cherry picking information without supplying the full story
You state that there is ‘no solid evidence that just-in case double mastectomy increases survival’. The reference you supplied for this (http://www.ncbi.nlm.nih.gov/pubmed/15495033) concludes that even taking into account the limitations of the studies in the review, that double mastectomy should be considered for very high-risk groups i.e. those with BRCA mutations – such as Angelina Jolie. Yet you do not state this anywhere in your article.
Misuse of references is a common theme in your article but one particularly glaring mistake appears in your sentence ‘new evidence shows that even a faulty BCRA1 gene, as Jolie has, may require epigenetic modification, or ‘silencing’ and deletion, before it can progress to cancer’ (http://breast-cancer-research.com/content/8/4/r38). The paper cited is clearly investigating the epigenetic control of ‘normal’ BRCA genes and how these changes could drive tumour progression by producing BRCAness. The author’s even state: ‘this lends support to the idea that epigenetic silencing of the BRCA1 gene might channel tumour progression, akin to an underlying BRCA1 germline mutation resulting in a BRCA-like phenotype’.
So once again your reference does not back up the claim that Angelina Jolie’s risk is not as high as she was told. More importantly, it does not justify printing information that claims BRCA mutations are not an important risk factor – or not as important as epigenetic changes. There is no evidence for this claim.
The final part of your article makes some very tenuous links to other risk factors that you are exposed to following a mastectomy. First off, anaplastic large-cell lymphoma (ALCL) is not a breast cancer; it is a lymphoma as is clear in its name. Second, the study you have cited is not particularly robust as it is a very small study from a distinct set of patients from Holland. They conclude that there is an association between breast implants and ALCL but that the overall risk is ’exceedingly low’. In fact, the risk of ALCL after implants is lower than the risk of breast cancer in the same setting!
There are many organisations that supply balanced health advice based on evidence that aims to help people make informed decisions. I think that you, by representing the evidence in this way, are putting dangerous health advice in the public domain that could be read by vulnerable people. This is a very serious issue as you could potentially put someone off having preventative surgery when the benefits far outweigh the risks for their particular circumstances. For those in the high-risk group, such as Angelina Jolie, there is plenty of evidence for the benefits of double mastectomy and I am happy to supply the research papers if you can’t locate them.
To end I will say that this is not the only misleading article that has come to my attention in your magazine and I would very much like to a response particularly for you to provide evidence to back up your claims, before I am forced to escalate the issue.
Matthew Lam, PhD MSB