Like pretty much everyone else this week, I paid a lot of attention to Angelina Jolie’s very brave decision to publicize her prophylactic bilateral mastectomy, and now her prophylactic oopherectomies (removal of her ovaries) in order to radically reduce her very high risk of breast and ovarian cancer. I won't repeat what many of us in the women's health community already knew: The statistics are out there, they're grim, and now the rest of you know, too.
Ms. Jolie sparked a conversation on topics that are hard to talk about, and she should be proud of the lasting impact her disclosure will have. When a sex symbol elects to remove her breasts, the culture is sure to explode. The internet is alive with discussions on everything from access to health care, to our class-based medical system, to the future of genomic-based individualized medicine. Add in cancer, fear of death, and boobs: BOOM!
I have a very busy practice in women’s health and am board certified in not only conventional obstetrics and gynecology, but also holistic and integrative medicine. I also have extensive formal training in Ayurveda, the ancient medical system of India. I meditate, do yoga, and use complementary practices such as herbal medicine and aromatherapy, in addition to practicing surgery and prescribing drugs. I appear on TV and teach nationally about integrating traditional holistic medicine with modern conventional practice to create the optimal healing environments for (and with) our patients.
My point? I'm a devout practitioner of mind-body-spirit medicine, and I feel compelled to join this important conversation.
Do I believe negative emotions such as fear can impact disease?
The research on nocebo and placebo effects is compelling indeed. Powerful data demonstrate that the way in which a doctor presents information can shape our patients’ decisions, beliefs, and ultimately—outcomes.
I've witnessed this repeatedly and have experienced the negative “nocebo” effects myself. (The course of my first child's birth was changed by doc-induced fear. But that's another blog post.)
We also know that we can alter outcomes with “alternative” practices like aromatherapy or loving therapeutic touch, which alter brain chemistry and therefore, processing. In fact, these are merely the biophysical explanations for a millennia’s worth of commonsense practices.
For instance, women supported during labor by a doula have lower rates of cesarean section and fewer medical complications.
Conversely, we know that fear and anxiety lower one’s pain threshold. If we anticipate pain, we feel it.
The field of psychoneuroimmunology elucidates the relationship between our thoughts and disease. The emerging field of epigenetics is blowing everyone’s mind. Turns out that our genes are not 100% fixed, but may be influenced both positively and negatively by things like how we eat and what we think.
So yes, science is only starting to catch up with what many of us in the MBG community have known for years: these ancient healing practices work, and the mind can be very powerful in terms of curing or causing disease.
But none of this means that science is wrong when it doesn't fit neatly into our worldview!
So let's clarify a bit here: When Ms. Jolie tested positive as a BRCA carrier, she wasn’t just “told by her doctors" that she had an 87% risk of breast cancer and 50% risk of ovarian cancer. These are facts based in genomic medicine and decades of solid research. And then there's this: when your mom dies of actual ovarian cancer, your point of reference radically shifts. Cancer becomes a real thing that happens to real people, very likely you! (All women have about a 1 in 90 lifetime risk of ovarian cancer; Angelina's risk shot up to 1 in 2 when she tested positive for BRCA.)
I don’t think sharing this information causes cancer down the line. And I don't think that offering a prophylactic bilateral mastectomy (currently the best means of prevention) creates the nocebo effect. In fact, I don't think it's fair or safe to suggest otherwise. As doctors, we need to be very mindful of not blaming or implying that cancer is a punishment for bad feelings, attitudes or thoughts.
In fact, in the case of BRCA carriers, their cancers have a genetic basis.
I would have made the exact same decision in Ms. Jolie’s shoes and have counseled many women to do so over the years. I also would have continued my mind-body practices to get through the tough stuff, and stay connected to life and love. In fact, I've supported many women through this very process.
I don’t think that using individualized genomic information to guide our choices is a slippery slope that could lead to the removal of otherwise healthy functioning body parts like appendices. In fact, as we enter what I hope will be a new era of medicine that is individualized based on our genes — genes that are, albeit, more malleable than we ever imagined—we need to become more literate and less fearful of science.
I absolutely appreciate the frustration at what seems like barbaric treatments in our health care system. Surgeries should be the last resort. Conventional medicine has relied far too long on treating symptoms rather than addressing the root cause of illness and focusing on prevention.
I've already had testing to better understand my health susceptibilities and what lifestyle changes I can make to prevent major challenges in the years to come. Today all babies are subjected to newborn screening to provide early detection and prevention strategies. I hope that someday all children will have even more extensive genetic analysis at birth, which might guide them through their lifetimes, because science will have evolved that far.
I look forward to a future where BRCA positive individuals can make conscious choices supported by solid scientific evidence to diminish risk that don't include lopping off their beautiful breasts.