Jolie strides out for all of womankind

Her double mastectomy and drive for affordable testing may yet be the movie star's greatest role

If this was Angelina Jolie's masterplan to divert attention away from her upper thigh, which she flashed to worldwide acclaim last year at the Oscars, it was an extraordinarily dramatic one.

Her revelation that, in order to avoid developing breast cancer, she had undergone a double mastectomy, expressed sentiments that were more than just survival, though her chances of succumbing to the disease fell from 87 per cent to just 5 per cent.

The power of what she wrote in the New York Times lies in the fact that she is feted for her looks and sexual allure - and that, while a lesser mortal may feel desexualised by the experience of losing her breasts, this icon of beauty apparently does not: "On a personal note, I do not feel any less of a woman. I feel empowered that I made a strong choice that in no way diminishes my femininity. I am fortunate to have a partner, Brad Pitt, who is so loving and supportive."

Along with reassuring us on the state of her body and the ongoing health of the Brangelina partnership, she does something rather surprising: she champions science as a means for women to shape their own medical destiny. And, while she's at it, she takes a much-needed swipe at the genetic testing industry for pricing breast cancer tests beyond the reach of most women.

Certainly, Jolie's account of how and why she came to lose her breasts constitutes a milestone in the public acceptance of what has tended to be seen as a rather extreme act of self-preservation.

The actress lost her mother, Marcheline Bertrand, at the age of 56 to the disease and wrote in the newspaper: "I can tell my children that they don't need to fear they will lose me to breast cancer."

"The article is a very brave thing for her to have done, especially as it looks as though she could have got away without saying anything," says Professor Alan Ashworth, chief executive of the Institute of Cancer Research and a member of the research team that discovered BRCA2 - one of the two key genes that, when mutated, contribute to inherited breast and ovarian cancers (Jolie carries a mutation on the other gene, BRCA1).

"The fact is that, with that mutation, she is at a very significant risk of breast cancer," Professor Ashworth says. "Women in her position are routinely offered the option of having their breasts and ovaries removed."

Jolie has not only normalised the idea of prophylactic surgery, he says, but flagged the need to make testing more affordable and accessible.

Jolie mentions that doctors told her she had a 50 per cent chance of contracting ovarian cancer, and many cases of breast cancer are actually driven by hormonal changes in the ovaries.

In life's genetic lottery, Jolie has so far been an enviable winner. Beautiful, rich and talented, she has a film star lover and six children, plus a creditable record as a UN special envoy for refugee issues. But her mother's battle with breast cancer, which started when she was only in her 40s, must have led Jolie to suspect the possibility of a genetic imperfection. The uncommon mutation in her BRCA1 gene could have been inherited from either her mother or her father, actor Jon Voight, who only found out about his daughter's operation at the same time as everyone else.

A family history of breast cancer, however, does not always mean that the smoking gun is a genetic one. In fact, at least 95 per cent of breast cancers are not associated with any specific genetic mutation. Instead, they are thought to result from a complex interplay of milder genetic risks and lifestyle factors, such as smoking and delayed motherhood.

But those who do test positive for either a BRCA1 or BRCA2 mutation - having both is virtually unheard of - live with a 50 to 80 per cent chance of developing breast cancer over their lifetime. This is the point at which a double mastectomy comes on to the radar, as well as ovary removal.

While breasts are relatively easy to screen for lumps, ovaries are not. Given that ovaries produce oestrogen, the hormone associated with ovarian and breast cancers, some women choose to cut their risk by having an oophorectomy (removal of ovaries), coupled with ongoing breast surveillance. Women often are given breast cancer drugs such as Tamoxifen or Raloxifene to cut their chances of cancer.

Despite these choices, some women still opt for breast removal. Jolie opted for the technique that is most like a standard boob job. First, she underwent a procedure to save her nipples - after first checking they were disease-free - and then had expanders put in to replace the removed breast tissue.

But there are two modern techniques that result in a more natural look. The first is autologous flap reconstruction, which involves replacing the removed breast tissue with the patient's own tummy tissue. Essentially, it's a tummy tuck and breast reconstruction rolled into one.

The other technique borrows muscle, skin and subcutaneous fat from the back. In cases where the nipple can be saved, about 60 per cent of its sensitivity can be preserved; breastfeeding, though, isn't possible.

Perhaps the biggest public service Jolie has done, though, is to highlight the stranglehold one company continues to exert over the domain of breast cancer testing.

The patents are held by Myriad Genetics, a Utah-based company that owns, and enforces, the worldwide rights to genetic tests relating to BRCA1 and BRCA2.

Myriad's monopoly is currently being challenged in the US Supreme Court by, among others, the American Civil Liberties Union, which is against the increasing corporatisation of the human genome (around 20 per cent of human genes are now subject to patents). That is a battle that Jolie, in her own way, may help to win.