Jolie Effect: BRCA Tests Up but No Change in Mastectomy

Fran Lowry

December 15, 2016

After Angelina Jolie announced in a 2013 New York Times editorial that she had undergone a double mastectomy because she carried BRCA1/2 gene mutations, breast cancer gene testing rose sharply among US women.

But there was no change in overall mastectomy rates and the rate actually decreased among women who had a BRCA test after the editorial was published.

The editorial was one of the most-viewed health-related articles in the age of social media, write coauthors Sunita Desai, PhD, and Anupam B. Jena, MD, PhD, both from Harvard Medical School, Boston, Massachusetts in the Christmas issue of the BMJ.

Dr Sunita Desai

"Her editorial was very effective in terms of raising awareness about this test, which hadn't been widely used at the time," Dr. Desai told Medscape Medical News.

"But the decrease in mastectomy in women who had the BRCA test after the editorial suggests that, while it was extremely effective in educating women about BRCA testing, and getting them to be tested, it wasn't necessarily targeting the subpopulation of women who needed it the most," she said.

Who Should Get Tested

BRCA1/2 mutations significantly increase the risk for breast and ovarian cancer.

The mutations are rare, found in about 2% to 4% of women, but are more likely in those with a family history of breast and ovarian cancer and those with personal risk factors, such as Ashkenazi Jewish descent, as reported by Medscape Medical News.

"These are the women with the highest pretest probability of having the mutation. Her editorial was a public health intervention, and in these types of awareness campaigns, the hardest thing is targeting the women who needed it the most," Dr Desai said.

Analysis Included More Than 9 Million Women

Using the Truven MarketScan commercial claims database that included 9,532,836 commercially insured women aged 18 to 64 years, Dr Desai and Dr Jena analyzed changes in BRCA testing rates in the 15 business days before and after Jolie's editorial was published on May 14, 2013, and compared them with the change in the same period in 2012.

They also compared mastectomy rates in the months before and after the editorial was published, both overall and within 60 days of BRCA testing.

They found that daily BRCA test rates increased immediately after the editorial appeared, nearly doubling, from 0.71 tests per 100,000 women in the 15 business days before publication to 1.13 tests per 100,000 women in the 15 business days after publication.

In comparison, daily BRCA test rates were relatively similar in the same period in 2012 (0.58 per 100,000 women in the 15 business days before May 14 vs 0.55 tests per 100,000 in the 15 business days after).

In sum, there was an absolute daily increase of 0.45 tests per 100,000 women, or a 64% relative increase (P < .001).

In the 15 days after publication, the editorial prompted an estimated increase of 4500 BRCA tests at a cost of $13.5 million. The increase in testing was sustained throughout 2013.

However, in the months following publication of the Jolie editorial, overall mastectomy rates remained unchanged, but 60-day mastectomy rates among women who had a BRCA test fell from 10% in the months before publication to 7% in the months after publication.

"We feel that this suggests that women who underwent BRCA testing as a result of the editorial had fewer risk factors and so a lower probability of having the BRCA mutation than women tested before the editorial," Dr Desai said.

Celebrity endorsements in general can be extremely effective in raising awareness. Dr Sunita Desai

"This is an observational study and so we cannot draw any firm conclusions about cause and effect. But we can say that Angelina Jolie's editorial and celebrity endorsements in general can be extremely effective in raising awareness and influencing healthcare utilization, especially in the social media age where these messages can be disseminated very quickly and broadly," she said.

Dr Desai also cautioned that targeting the right subpopulation can be difficult and that these messages could lead to some inappropriate overutilization.

"A lot of the women who got the tests probably did not need them to begin with," she said.

Before women undergo this type of genetic testing, talking with a genetic counselor or other healthcare professional first is advised. Dr Desai concluded: "All healthcare should be personalized. Something that is right for one woman might not be right for someone else."

Dr Desai and Dr Jena have disclosed no relevant financial relationships.

BMJ 2016;355:i6357. Abstract

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