Angelina Jolie Undergoes Second Preventative Cancer Surgery

Angelina Jolie has written a second op-ed piece for the New York Times concerning her health.

As you probably recall, the first time she did this in May 2013, was to announce that she had undergone bilateral mastectomies after testing positive for the BRAC 1 gene.

Because she tested BRAC1-positive, and her mother, actress Marcheline Bertrand, died at the age of 56 from ovarian cancer, Jolie has been followed very closely for early signs of ovarian cancer. This included bloodwork looking for an ovarian cancer-associated marker called CA-125, as well as other less specific inflammatory markers. She anticipated that at some point she would undergo an elective removal of her ovaries to reduce her risk of cancer.

Two weeks ago Jolie got news from her doctor that although her CA-125 numbers were normal,

“ [He said] ‘There are a number of inflammatory markers that are elevated, and taken together they could be a sign of early cancer.’ I took a pause. CA-125 has a 50 to 75 percent chance of missing ovarian cancer at early stages’, he said. He wanted me to see the surgeon immediately to check my ovaries.”

Jolie was seen by the surgeon who treated her mother and underwent an ultrasound, a CT scan and a PET scan. In a PET scan, a very small amount of radioactive glucose (sugar) is injected into a vein. The PET scanner rotates around the body and makes a picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because they are more active and take up more glucose than normal cells do.

Fortunately, no tumors were found, although very early stage cancer could not be completely ruled out.

After speaking “to many doctors, surgeons and naturopaths” Angelina decided to undergo a laparoscopic bilateral salpingo-oophorectomy- i.e. she had both her ovaries and fallopian tubes removed.

“There was a small benign tumor on one ovary, but no signs of cancer in any of the tissues.”

The main consequence of the surgery is that it forces a woman into menopause, and replacement hormones are needed to prevent severe symptoms:

“I have a little clear patch that contains bio-identical estrogen. A progesterone IUD was inserted in my uterus. It will help me maintain a hormonal balance, but more important it will help prevent uterine cancer. I chose to keep my uterus because cancer in that location is not part of my family history.”

Angelina, once again, says she has come forward to speak about her medical journey to let “other women at risk to know about the options.”

“There is more than one way to deal with any health issue. The most important thing is to learn about the options and choose what is right for you personally.”

You can read the entire op-ed by clicking here.

A quick anatomy lesson

The ovaries are a pair of organs in the female reproductive system. They are in the pelvis, one on each side of the uterus (the hollow, pear-shaped organ where a fetus grows). Each ovary is about the size and shape of an almond. The ovaries make eggs and female hormones (estrogen and progesterone).

The fallopian tubes are a pair of long, slender tubes, one on each side of the uterus. Eggs pass from the ovaries, through the fallopian tubes, to the uterus.

The peritoneum is the tissue that lines the abdominal wall and covers organs in the abdomen.

What research is now telling us about ovarian cancer…

Current research on ovarian cancer is turning the way one thinks about ovarian cancer on its head!

Conventional wisdom has it that ovarian cancer (technically called epithelial carcinoma of the ovary) begins in the ovary, spreads locally and eventually spreads to distant sites.

Now, based on histopathology (how the cells look under the microscope), molecular and genetic studies, it seems that what we have called ovarian cancer may actually arise from the finger-like projection at the end of the Fallopian tubes called the fimbriae. The cancer cells spread from the Fallopian tubes into the epithelium which cover the ovaries.

The most common histology of ovarian cancer is called high-grade serous carcinoma. The same types of cells are also found in cancer that arise in the peritoneum. For these reasons, some physicians are now saying that ovarian cancer should be renamed pelvic serous carcinoma.

Cancer of the ovary is one of the most common gynecologic cancers and the fifth most frequent cause of cancer death in women. This new view of the model of ovarian cancer may have huge implications for treatment and prevention of the disease.

For women at high risk for ovarian cancer without evidence of disease, removal of the Fallopian tubes (tubectomy), while leaving the ovaries in place may be enough to lower the risk of cancer. This would also prevent the two most difficult consequences of bilateral salpingo-oophorectomy- forced menopause and infertility. Leaving the ovaries maintains estrogen and progesterone levels and allows ovulation. Fertility could be preserved by harvesting a patient’s own eggs, fertilizing and implanting them into her uterus. A patient could have her own biologic children. Studies are underway to assess whether the tubectomy will be as protective as the total procedure, and which patients would be the best candidates for it.

See this 2016 article by Dr. Robert Kurman, Director of the Division of Gynecologic Pathology at the Johns Hopkins University School of Medicine: Kurman PSC 2016