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France's bias against preventive mastectomy


American women at high risk for breast cancer, such as Angelina Jolie, often opt for a preventive mastectomy. But in France, women tend to stay away from the surgery, preferring to be closely monitored by doctors.


In revealing her double mastectomy on Tuesday, actress Angelina Jolie raised questions about cancer prevention treatments around the world, especially in countries like France, where preventive mastectomy is rarely recommended by doctors.

Angelina Jolie, the new face of the fight against cancer

One in eight women are diagnosed with breast cancer in France, according to the Institut Curie, one of the largest cancer research centres in Europe.

“In a lifetime, women in France have a 12 percent chance of developing breast cancer,” said Dr. Pascale This, from the Institut Curie, a figure that makes it one of the most common types of cancer found in French women.

Some women, like Angelina Jolie, are at higher risk than others, including those with a strong family history of cancer. They often carry a mutation on the BRCA1 or BRCA2 genes that makes them more vulnerable to developing the disease.

“It’s important to make clear that it’s the mutation on those genes that puts the women at risk, not the genes themselves,” said Dr. This.

“The women who carry the BRCA1 mutation see the chances [on average] of developing breast cancer rise to 65 percent, and 45-50 percent for those carrying the BRCA2 mutation,” she said.

Learning that you have the faulty gene, thanks to a simple blood test, can greatly diminish the risk of developing breast cancer.

A free but complicated procedure in France

However, prevention options available to those women are regarded differently in France and the US.

Myriad Genetics, the only US lab that offers the test, owns the patents for the gene tests available in the US, which cost between $3,000 to $4,000 each. Last month, the US Supreme Court took up the issue of whether human DNA can be the subject of a patent and a decision in the case is expected in a few weeks. Experts believe a decision against Myriad would help reduce the cost of the tests and increase access.

In the US, high-risk women who can afford the $3,000 genetic test can simply walk into a centre to have their blood drawn, then send it to Myriad Genetics, the only lab in the US to offer the test. If the test indicates a gene mutation, a woman can choose to undergo a preventive mastectomy, reducing her risk of breast cancer by 95 percent.

French patients, on the other hand, face a longer process.

First, they go to an oncology consultation to determine their risk level. If doctors consider the risk level high enough, they can prescribe the genetic test for free through the public health-care system.

If and when the genetic mutation is diagnosed, patients are then given two options: the preventive mastectomy or specialised close monitoring, with regular mammograms and scans. “Doctors in the US, in the Netherlands or the UK generally recommend the surgical procedure, but not in France,” said Dr. This.

French women 'culturally' opposed to mastectomy

Although doctors in France explain the mastectomy procedure and present it as an option to their patients, they tend to advise against it. “We prefer the screening method, where we can detect cancer at its early stages, rather than the preventive method,” she said.

But there are also downsides to choosing monitoring over the mastectomy. “There is no guarantee of a risk reduction, and it can be very nerve-wracking,” added Dr. This.
Yet, she said, five percent of patients in France choose the preventative mastectomy. “It’s a very long and tough procedure with physical and aesthetic consequences,” she said, adding that “with a loss of sensitivity in the nipple area, it can also have an impact on women’s sex life.”
In the US, the Netherlands or the UK, the number of at-risk women who opt for a preventive mastectomy ranges from 30 to 40 percent, according to Insitut Curie figures. “They are more pragmatic,” said Dr. This, adding that French women tend not to undergo the "mutilating procedure" for “cultural reasons.”
Will Angelina Jolie’s publicised choice change French doctors' and patients' attitude towards mastectomy in France? Dr. This doesn’t think so. “We won’t offer mastectomies to patients who don’t go through the full process,” she said. Women who want the mastectomy will still have to face reluctant doctors.
However, Dr. This still thinks Angelina Jolie’s choice, and the media buzz around it, has benefits, and raises awareness. “Access to information is of the utmost importance. From an ethical point of view, all women need to be informed of their options,” she said.
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