TIME medicine

How 3D Imaging Can Tell Exactly How Old You Are

You may be able to dodge questions about your age, but your face can’t

For the first time, scientists have used 3D imaging of a people’s faces to predict their age. The 3D information was so accurate, in fact, that it was better at pinpointing age than the best known marker, a test that involves studying the DNA.

Reporting in the journal Cell Research, Jing-Dong J Han, from the Chinese Academy of Sciences-Max Planck Partner Institute for Computational Biology, found that certain facial measures are reliable predictor’s of a person’s biological age. The researchers analyzed 3D facial images from more than 300 people, and matched them up with measurements from several dozen blood markers including cholesterol and albumin. Specifically, the width of the mouth and nose, and the distance between the mouth and nose tend to expand with age, and the eyes tend to droop over time. Measuring this change provides a relatively stable way of tracking, and predicting, a person’s age.

“Overall facial features show higher correlations with age than the 42 blood markers that are profiles in routine physical exams,” says Han.

 

Weiyang Chen–2015 Nature Publishing Group. Visualizations of facial aging.

MORE: Human Faces Can Express at Least 21 Distinct Emotions

She arrived at the finding after hearing a colleague present work on using 3D facial images to quantify racial differences. “It immediately struck me that facial images might be a potential good phenotype to include in our study to quantify the extent of aging,” she says. “I did not expect to see such remarkable changes with age, nor did I expect the 3D images to be such an accurate biomarker for biological age.”

Why is it important? Han says that pinpointing how quickly a person is aging via the relatively easy 3D algorithm could have useful health implications that go beyond keeping people honest about their age. Such a measure might provide a window into deeper physiological processes that could be aging abnormally fast. “It might have important implications for assessing the risks of aging-associated diseases, and for designing personalized treatment schemes to improve their life styles and health,” she says.

TIME Exercise/Fitness

This Study Busts Your Work Out Excuse

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Brent Winebrenner—Getty Images/Lonely Planet Images

Air quality may not be the best in cities, but the benefits of physical activity can outweigh the harms of breathing in pollutants

Exercising outdoors is certainly preferable to being cooped up in a stuffy gym, but if you live in an urban area, the pollution from cars and buses may give you pause. It shouldn’t. Zorana Andersen from the center for epidemiology and screening at the University of Copenhagen and her colleagues report in the journal Environmental Health Perspectives that being active trumps some of the negative health effects that breathing in polluted air might have.

MORE: Pollution: Dangerous to Joggers

In a study involving 52,061 people who were followed for around 13 years, Andersen found that those who were more active were less likely to die during the study than those who were more sedentary, regardless of the pollutant levels where they lived. The researchers asked the participants to detail their physical activities, including their leisure sports, how much they walked, whether they biked or walked to work, and whether they spent time gardening. They compared these responses to the levels of nitrogen dioxide near their homes; NO2 is a gas produced from the burning of fossil fuels in cars, and is an ingredient for other harmful pollutants such as ozone and particulate matter, which can cause respiratory illnesses. Previous studies found that walking along a busy London street, for example, caused a drop in lung function and that cycling or running near high traffic roadways also compromised people’s respiratory functions slightly.

In Andersen’s study, however, people who participated in sports showed a 22% lower risk of dying from any cause during the 13-year followup, while those who cycled regularly showed a 17% lower risk and people who spent time gardening showed a 16% lower risk compared to those who didn’t do either of those activities — and regardless of the pollution levels where they lived.

MORE: Ozone Can Harm the Heart in as Little as Two Hours

“We found an even more positive message around physical activity than we even hoped for,” says Andersen. “Physiologically it’s plausible that you inhale more particles [of pollution] when you exercise in polluted areas, and we thought maybe the accumulated lifetime effect of this would reduce the benefit of exercise. But we don’t see that.”

Essentially, the benefits of being active were strong enough to overcome some of the negative effects of breathing in pollutants. That makes sense, she says, because even if people aren’t exercising to avoid inhaling pollutants, they are still exposed to them, and Andersen’s study shows that even if exercises might be exposed to slightly higher levels of compounds like NO2, that still doesn’t negate the positive effects of physical activity on their heart, blood sugar levels and more. In fact, for specific conditions, the benefits of exercising remained quite high; active people even in highly polluted areas had a 66% lower chance of dying early from diabetes compared to those who didn’t exercise.

She notes, however, that some cities may have significantly higher pollution levels than Copenhagen, where the participants lived, and it’s not clear yet how greater concentrations can affect the exercise-pollution-mortality balance. So if you have a choice for working out, biking or walking in a less polluted area, however, such as a park or a quieter side street, that might be a good idea. But don’t worry too much if you don’t. “Being active prolongs life more than staying away from air pollution,” says Andersen. “So pollution shouldn’t be a barrier to exercise.”

TIME medicine

Who Should—And Who Shouldn’t—Take Vitamin D

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Here's what experts say, based on the latest evidence

Does your diet need a little extra D? For researchers, it’s one of nutrition’s most vexing questions. “It’s the wild, wild west,” says Dr. JoAnn Manson, chief of preventive medicine at Brigham and Women’s Hospital and professor of medicine at Harvard Medical School. “The issue has become murkier over time rather than clearer.” Research is mixed about whether doctors should routinely test for vitamin D levels, like they do for cholesterol, and whether people should be supplementing their diets with vitamin D pills.

Case in point: a study just released in JAMA Internal Medicine showed that vitamin D did not lower the risk of falls among an elderly population in Finland. The study, which compared the effects of exercise against vitamin D supplements on falls and resulting injuries, did find, however, that exercise cut the chances of more severe injury from falls in half compared to those who didn’t exercise.

MORE Want to Stay Healthy? Don’t Rely on Vitamins

But that doesn’t mean that vitamin D isn’t worth taking at all. The Institute of Medicine (IOM), and the U.S. Preventive Services Task Force (USPSTF) both recently reviewed all of the evidence on vitamin D and its health effects and concluded that in many cases, D supplementation is beneficial—with some important caveats. The two groups say that 600 international units (IU) are generally enough for most healthy adults and that higher doses of vitamin D don’t necessarily produce more health benefits. They also stress that those benefits are limited to bone health; there isn’t enough evidence to support the idea that taking the vitamin can protect against heart disease, cancer, diabetes or cognitive decline, all benefits suggested by some smaller studies.

“More isn’t necessarily better,” says Manson, who served on the IOM committee. “In some cases, it can be worse.”

Overdoing vitamin D can lead to calcium in the urine, which can cause kidney stones. Extremely high doses—around 10,000 IU a day—can trigger calcium deposits in the blood vessels, which can lead to clots that cause heart attacks. The IOM panel recommended no more than 4,000 IU of vitamin D daily to avoid these potential problems.

MORE Want to Build Endurance? Cut Back on Vitamin C and E Supplements

When people are tested for vitamin D deficiency and come up short, some researchers caution against treatment. In addition to the dosage risks, there’s also evidence that the lab tests for the type of vitamin D circulating in the blood, 25-hydroxyvitamin D, may not be the most reliable measure of a person’s D levels. Plus, not all labs use the same standard test for picking up 25 hydroxy D, and they set different standards for what are considered normal levels. “Clinicians are often left chasing a number, and trying to get patients’ blood levels up to a certain point,” says Manson. “But when you think about how many people are screened for vitamin D, and the concerns about the reliability in how it’s measured, and the differences in what is considered normal ranges across laboratories, it’s really concerning.”

Better data may be coming soon, however. Several large trials are underway in which people are randomly assigned to take different levels of vitamin D supplements so researchers can study their health outcomes, from bone problems to heart disease, cancer, diabetes and more. Manson is overseeing the largest of these, called VITAL, which has 26,000 participants. The results from these studies, which are being conducted in the U.S., Europe, Australia and New Zealand, should be available in 2017. “We should have conclusive answers in about three years,” Manson says.

The studies will also look specifically at whether vitamin D levels and metabolism differ across racial and ethnic groups. Some studies have hinted that disparities by race in heart disease and certain cancer risks may be due to vitamin D, and the randomized trials will hopefully provide more information on whether that’s true.

In the meantime, Manson says doctors and patients should follow the IOM and USPSTF guidelines: doctors should not order vitamin D blood tests for all of their patients, and people shouldn’t take more than 600 IU of the vitamin if they are otherwise healthy. The only people who may need regular testing for vitamin D deficiency, and possible supplementation, are those with malabsorption problems like Celiac disease, those who have had bypass surgery, or people who have already had fractures and have been diagnosed with osteoporosis. People taking certain medications, including treatment for tuberculosis, may also need to consider vitamin D pills.

For everyone else, however, universal screening isn’t necessary—and there isn’t any reason to take more than the recommended daily allowance of vitamin D.

Read next: The 4 Most Confusing Things About Sugar

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TIME Depression

How Pilots Are Screened for Depression and Suicide

While it’s not clear exactly why Germanwings Flight 9525 crashed into a French mountainside, the black box from the cockpit raises questions about whether mental health issues were involved, and how aviation officials identify and monitor the mental health of pilots.

Prosecutor Brice Robin said that the cockpit recordings suggest the lead pilot was locked out of the flight deck after leaving for the restroom, and that co-pilot Andreas Lubitz “voluntarily allowed the aircraft to lose altitude. He had no reason to do this. He had no reason to stop the captain coming back into the cockpit.” As investigators search for a second black box, experts are trying to piece together the reasons why Lubitz acted the way he did. His mental state remains a possible cause.

If the investigation reveals that mental health played a role, it wouldn’t be without precedent. In a 2014 study in the journal Aviation, Space and Environmental Medicine, researchers looked at 20 years of data for what they called “aircraft assisted suicide.” From 1993-2012, 24 of 7,244 plane crashes were thought to be deliberately caused by a pilot. That’s less than 1% of the total, but it’s still enough to raise questions about the mental health stressors of pilots.

“I really wish that we had some kind of deeper thinking about this issue, because it’s one of the most difficult in aviation medicine,” says Alpo Vuorio, MD, PhD, the study author and an aviation specialist in occupational medicine at the Mehiläinen Airport Health Centre in Finland. He screens pilots and cabin crew of commercial airlines for health issues—including mental health issues—and says he sees any given commercial pilot once a year for a short visit.

Commercial pilots have to pass a physical and mental evaluation every six months (for those over 40) or once a year (for those under 40) in order to be certified to fly a passenger plane. The emphasis, however, is on the physical and less on the mental, mainly because mental health is harder to quantify.

“You somehow try to see if the pilot is well, and it’s not the easiest thing,” Vuorio says. Pilots answer yes-or-no questions about their mental health, Vuorio says, like if they’ve ever tried to attempt suicide or visited a psychiatrist. “You speak yes or no, but it’s up to you, what you tell,” he says. Pilots can visit several different locations for these examinations, he says, and if they don’t occur in house, past data don’t appear on the screen.

And pilots aren’t likely to divulge any potential mental health problems, including signs of depression or anxiety, because that would take them out of the sky. “Pilots aren’t going to tell you anything, any more than a medical doctor would about their mental health,” says Scott Shappell, professor of the Human Factors Department at Embry-Riddle Aeronautics University who is a former pilot and crash scene investigator.

Pilots, like doctors and policemen and others with high-stress jobs, tend to be good at compartmentalizing — walling off difficult or emotional experiences so they don’t interfere with their ability to function day-to-day. Medical examiners who evaluate pilots for their recertification also aren’t always trained in mental health, so they may not recognize subtle signs of conditions such as depression or alcoholism.

According to Dr. William Sledge, medical director of the Yale-New Haven Psychiatric Hospital who has evaluated pilots for the Federal Aviation Administration, about 40% of pilots he saw were for alcohol related problems, and a third for depression or anxiety. Only about half of the latter group reported their problems themselves, however. The other half were referred to Sledge only after incidents required their superiors to intervene.

“The problem is there is no incentive” to report mental health issues, says Shappell. “They know that if they self report, the way the system is designed, it will be a black mark.”

In a statement, the FAA said: “Pilots must disclose all existing physical and psychological conditions and medications or face significant fines of up to $250,000 if they are found to have falsified information.”

In the case of mental health evaluations, pilots are taken off the flight schedule while they are treated or begin antidepressant medications. Until 2010, even these drugs were banned, and pilots required them could no longer fly.

When the U.S. Air Force began requiring annual suicide prevention and awareness training in 1995, including screening for mental illness, the suicide rate plummeted from about 16 suicides per 100,000 members to about 9.

Even for experts, however, judging whether a pilot is suicidal is one of the hardest parts of the job. That’s no surprise, since the struggles of spotting and talking about suicide plague our entire society, says Barbara Van Dahlen, a licensed clinical psychologist and the founder and president of Give an Hour, a network of volunteer therapists. “In our society we are so quick to try to make it ok, to say it will pass and to say suck it up,” she says. “We really don’t listen to ourselves and we don’t listen to others very effectively.”

But pilots and others in high-pressure occupations face several unique stressors, she says, like having a physically demanding job and being responsible for other lives. “In a lot of positions of authority and leadership, those people are supposed to be capable and on top of things,” she says. “They don’t have a lot of people to share with and talk to, to be less than perfect and less than OK. That adds to the stress.”

One study of suicides among general aviation pilots—civilians who aren’t leading scheduled commercial flights—published in the journal Aviation, Space and Environmental Medicine, looked at 21-years’ worth of general aviation accidents as reported by the National Transportation Safety Board between 1983-2003. During that time, 37 pilots either committed or attempted suicide by aircraft, and nearly all resulted in a fatality. 38% of the pilots had psychiatric problems, 40% of the suicides or attempts were linked to legal troubles, and almost half, 46%, were linked to domestic and social problems. 24% of the cases involved alcohol and 14% involved illicit drugs.

Having ready access to a plane also seemed to be a contributing factor, too; 24% of the crashed planes in the study were used illicitly.

Read next: German Pilots Cast Doubt on Blaming of Co-Pilot for Crash

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TIME medicine

What We Learn When We Sequence the Genes of an Entire Nation

In a genetic milestone, researchers have amassed DNA data from an entire population of people. Here’s what we can learn from that information

Experts say that genetic sequencing may be the future of medicine, shaping how we understand and ultimately treat disease. If that’s the case, then the people of Iceland have a leg up on the rest of us.

In four groundbreaking papers published in Nature Genetics, scientists from Iceland describe the results of a massive gene-sequencing effort involving 2,636 people. Because the island country is relatively isolated, it’s a genetic goldmine. It enjoys a founder effect, which means that most residents can trace their lineage back to a few founding fathers, and that genetic variants have been passed down from generation to generation. That makes it possible to infer the distribution of the genetic variants found in the study’s 2,636 people to the remaining 325,000 Icelanders.

When they did that, the researchers, led by Kari Stefansson, CEO of deCODE Genetics/Amgen, were able find mutations linked to Alzheimer’s disease, liver disease, thyroid disorders and atrial fibrillation. They also identified almost 8% of the population who have lost function of at least one of their genes and calculated the rate of mutations in the Y-chromosome among men.

In recent years, the practice of mining large numbers of human genomes by comparing people with and without specific diseases has led to a growing list of genetic culprits behind conditions such as Alzheimer’s, cancer and more. But by studying such a genetically unique population, Stefansson says, he was able to pick up even rare genetic changes that have emerged more recently and occur less frequently but might still be important contributors to disease. Those, he says, will be important clues to better understanding the biological roots of health problems, as well as finding new drugs and treatments for them. “What we anticipate is that all human diversity is going to be explained by the diversity in the sequence of the genome, either solely by the diversity in the sequence or by the interface of that diversity and the environment,” he says. “That includes the diversity and risk of disease and the ability to resist them.”

MORE: The Iceland Experiment

The mutation associated with Alzheimer’s, for example, in the ABCA7 gene, hasn’t popped up in previous searches, but the gene is involved in transporting lipids across membranes, a process that may contribute to the build up of sticky protein plaques in the brains of Alzheimer’s patients.

The people who have lost function of at least one gene—called knockout genes in the genetic world—could also provide valuable hints about the pathways to disease. Even with a gene knocked out, most of these people are functioning, and Stefansson says researchers still study them in more detail to figure out how they are affected by their non-functioning genes. In animal research, knockouts are useful to see how prominent and important a gene is for health functioning. Stefansson anticipates that there may be redundancies built into the human genome to compensate for some knockouts, so finding these backup systems might be key to understanding why certain people get sicker with a disease while others remain relatively unaffected.

MORE: Scientists Identify Rare Gene Mutation that Protects Against Alzheimer’s

The sequences are also giving scientists a sharper picture of our past. The Y chromosome analysis shows that the last common ancestor sharing the Y chromosome among homo sapien men dates back 239,000 years, putting it closer to the common ancestor for the mitochondrial DNA passed down by women via their eggs. It also revealed how quickly mutations on the Y chromosome are occurring, which “gives us information about the age of our species, which is related to how diverse we are,” says co-author Agnar Helgason of deCODE and University of Iceland. “It tells us how quickly we are evolving.”

deCODE, which was acquired by the biotechnology company Amgen in 2012, is also investigating the new trove of genetic information for possible drug targets. “What this kind of work and insight into the human genome does is make approaches to influence the genome [and find treatments for disease] more rational,” says Stefansson.

How quickly that will happen isn’t clear yet, but having more information could make the process more efficient. “I’m willing to go so far as to say that there is nothing in human nature that may not have a reflection in the genome, or have something in the genome that associates with it,” he says. “We are made from the basis of the information coded in the genome.”

TIME neuroscience

How Air Pollution Affects Babies in the Womb

Silhouette of Pregnancy
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A new study finds evidence that prenatal exposure to common pollutants can contribute to hyperactivity, aggression and more in kids

It makes sense that an expectant mom’s exposure to pollutants in the air can affect her still-growing baby’s lungs and respiratory system. But there’s increasing evidence that such compounds can also harm brain development and contribute to behavioral and cognitive problems later in childhood.

In the latest study on the subject, published in JAMA Psychiatry, researchers for the first time pinpointed exactly which areas of the brain are affected if a baby is exposed to car exhaust and the byproducts of burning home heating oil. These polycyclic aromatic hydrocarbons (PAHs) have previously been linked to developmental delays, lower verbal IQ. signs of anxiety depression and problems with attention. But researchers haven’t been able to identify which areas of the brain are most vulnerable.

MORE: Children Exposed to More Brain-Harming Chemicals Than Ever Before

In this study, they recruited 40 mothers and their children living in the inner city who were participating in an ongoing study of pollution’s effect on development. They were selected because they had low exposure to environmental factors other than PAHs that could affect development, such as tobacco smoke, lead, insecticides and other chemicals. Based on measurements of PAH in their surroundings, about half of the mothers had PAH exposures below the median of those in the larger group, and half had PAH exposures higher than the median.

“The effects were extraordinarily powerful,” says Dr. Bradley Peterson, director of the Institute for the Developing Mind at Children’s Hospital Los Angeles and lead author of the study. “The more prenatal exposure to PAH, the bigger the white matter problems the kids had. And the bigger the white matter problems, the more severe symptoms of ADHD, aggression and slow processing they had on cognitive tasks.”

MORE: Mom’s Exposure to Air Pollution Can Increase Kids’ Behavior Problems

White matter is made up of the fibrous connections between nerve cells and is critical to helping neurons from one part of the brain communicate with their counterparts in other regions, and the babies with the highest exposure to PAH in the womb showed a dramatically lower volume of white matter in the left side of their brains. The entire left hemisphere, from the front to the back, was affected. “You would assume that an environmental exposure brought in by the blood and circulating to the brain would affect both sides of the brain,” says Peterson. “But the adverse effects of PAHs is located on one side; that’s surprising.”

The asymmetrical effect speaks volumes about how PAHs target brain tissue. Like other neurotoxins, they may preferentially seek out actively developing tissue. During gestation, the left side of the brain, which houses language capabilities, may be undergoing more intense structural changes in preparation for birth. This was supported by the fact that in the larger group of children in the study, those who were exposed to PAHs around age five didn’t show the same left-sided bias; in the older children, the pollutants affected both sides equally because the right hemisphere of the brain is undergoing active development at that time as well.

MORE: ADHD Linked to the Air Pregnant Women Breathe

Peterson suspects that the connection between PAHs and later behavioral and cognitive symptoms such as inattention, hyperactivity and slow processing speed may be due to how PAHs disrupt the normal communication between nerves in the left side of the brain and elsewhere.

The problem, he admits, is that moms-to-be can’t easily change where they live or work. And most people aren’t aware of how many PAHs they absorb on a daily basis. There are ways to minimize the risk of exposure, however. Expectant mothers can avoid secondhand smoke, a major source of the compounds. Not directly inhaling exhaust from cars on busy streets or smoke from fireplaces can also help, as can spending as much time as possible in parks or other areas free of burning fuels. It won’t eliminate the risk from living in an inner city and being surrounded by car emissions, but it can help, Peterson says. “Even if you can reduce your exposure from moderately high to moderate levels, it’s going to have a beneficial effect on the developing fetus,” he says.

TIME neuroscience

Your Brain Learns New Words By Seeing Them Not Hearing Them

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Chris Ryan—Getty Images/Caiaimage

To be a really proficient reader, it’s not enough to “hear” words. You also have to see them

We start to talk before we can read, so hearing words, and getting familiar with their sounds, is obviously a critical part of learning a language. But in order to read, and especially in order to read quickly, our brains have to “see” words as well.

At least that’s what Maximilian Riesenhuber, a neuroscientist at Georgetown University Medical Center, and his colleagues found in an intriguing brain-mapping study published in the Journal of Neuroscience. The scientists recruited a small group of college students to learn a set of 150 nonsense words, and they imaged their brains before and after the training.

Before they learned the words, their brains registered them as a jumble of symbols. But after they were trained to give them a meaning, the words looked more like familiar words they used every day, like car, cat or apple.

MORE: Mistakes to Avoid When Learning a Foreign Language

The difference in way the brain treated the words involved “seeing” them rather than sounding them out. The closest analogy would be for adults learning a foreign language based on a completely different alphabet system. Students would have to first learn the new alphabet, assigning sounds to each symbol, and in order to read, they would have to sound out each letter to put words together.

In a person’s native language, such reading occurs in an entirely different way. Instead of taking time to sound out each letter, the brain trains itself to recognize groups of letters it frequently sees together — c-a-r for example — and dedicates a set of neurons in a portion of the brain that activates when these letters appear.

In the functional MRI images of the volunteers’ brains, that’s what Riesenhuber saw. The visual word form area, located in the left side of the visual cortex, is like a dictionary for words, and it stores the visual representation of the letters making up thousands of words. This visual dictionary makes it possible to read at a fast pace rather than laboriously sounding out each letter of each word every time we read. After the participants were trained to learn the meaningless words, this part of their brains was activated.

MORE: An Infant’s Brain Maps Language From Birth, Study Says

“Now we are seeing words as visual objects, and phonetics is not involved any more,” he says. “We recognize the word as a chunk so we go directly from a visual pattern to the word’s meaning, and we don’t detour to the auditory system.”

The idea of a visual dictionary could also help researchers to better understanding reading or learning disorders like dyslexia. More research could reveal whether the visual word form area in people with such disabilities is different in any way, or whether they tend to read via more auditory pathways. “I helps us understand in a general way how the brain learns, the fastest way of learning, and how to build on prior learning,” says Riesenhuber.

TIME Cancer

Why Angelina Jolie Chose to Have Her Ovaries Removed

"This surgery decision is more straightforward than the decision to have the breasts removed.”

In an op-ed in the New York Times, Angelina Jolie Pitt announced that she recently had surgery to remove her ovaries and fallopian tubes. The procedure put her into menopause at age 39, and she will take replacement hormones for another decade or so.

“It is not easy to make these decisions,” she writes. She describes how she felt she “still [had] months to make the date” for her operation as she prepared herself both physically and emotionally to end her reproductive years.

MORE: The Angelina Effect

But cancer experts say that Jolie did the right thing. While her decision to remove both her breasts before she developed breast tumors was controversial, her latest choice to have her ovaries removed is less so, although equally difficult from both an emotional and physical point of view. “This surgery decision is more straightforward than the decision to have the breasts removed,” says Dr. Karen Lu, chair of gynecologic oncology at MD Anderson Cancer Center. “And it’s definitely a stronger recommendation than for the bilateral prophylactic mastectomy.”

For women like Jolie, who harbor either of the BRCA1 or BRCA2 mutations (Jolie is positive for BRCA1), their risk of breast cancer is anywhere from 80% to 90% higher than that of women without the genetic aberrations. But there are ways that doctors can screen for even the smallest tumors in the breast and therefore get a heads up when the cancer is growing. That allows many women to choose to keep their breasts and have a lumpectomy followed by radiation, with more frequent and vigilant screening for any additional or recurrent growths.

There isn’t that luxury with ovarian cancer, which is often caught once the cancer has progressed and is harder to treat. Women with the BRCA mutations have an up to 50% greater chance of developing this type of cancer, and there are no good ways of screening for it; a blood test that picks up a protein common to ovarian tumors isn’t specific to the cancer, so it could provide false positive or false negative results. In most cases, the cancer is well advanced before doctors, or patients, even know it’s there. “It is incurable in most cases for the vast majority of women,” says Lu.

That’s why the National Comprehensive Cancer Network, and the American Congress of Obstetricians and Gynecologists strongly recommend that women with BRCA1 mutations have their ovaries and fallopian tubes removed by age 40, and those with BRCA2 mutations by age 45.

MORE: Angelina Jolie’s Double Mastectomy: What We Know About BRCA Mutations and Breast Cancer

That doesn’t mean it isn’t still a difficult one to make. For women who learn they have a BRCA mutation in their 20s or 30s, for example, and have no history of cancer — yet —they have to decide whether they want to have children at all, or whether they want to continue adding to their family if they already have, or whether they are ready to enter menopause. For such pre-vivors of cancer, who are at higher risk of the disease but haven’t yet developed tumors, the choice between invasive surgery, and a theoretical risk of something occurring in the future, is agonizing.

For them, there may be other options soon. Researchers at MD Anderson, for example, are testing whether women and keep their ovaries for a little longer if they have their fallopian tubes removed first, since there are signs that ovarian cancer may start in the tubes. Jolie writes about promising studies that suggest birth control pills can lower the risk of ovarian cancer in women with BRCA mutations, but the data is still conflicting.

For now, the option that gives women with BRCA their best chance of avoiding ovarian cancer is surgery.”We are absolutely trying to develop medicinal approaches to reducing risk, and understand the disease better,” says Dr. Larry Norton, medical director of the Evelyn H. Lauder Breast Center at Memorial Sloan Kettering Cancer Center. “But right now, as of this minute, there is no medicinal or herbal approach to reduce risk anywhere close to what we can do with surgery.”

“I feel deeply for women for whom this moment comes very early in life, before they have had their children,” Jolie writes. “But it is possible to take control and tackle head-on any health issue. I feel at ease with whatever will come, not because I am strong but because this is a part of life. It is nothing to be feared.”

MORE: Angelina Jolie’s Double Mastectomy: It’s Not the Only Option

TIME medicine

Many Doctors Don’t Tell Patients They Have Alzheimer’s

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It’s hard to believe in today’s era of transparency in modern medicine, but there’s a diagnosis that doctors still try to keep from their patients

In a surprising new survey of patients who were asked about their interactions with their doctors, 45% of people whose doctors treated them for Alzheimer’s never told these patients that they had the degenerative brain disorder.

Led by researchers at the Alzheimer’s Association, the scientists looked at Medicare claim data from 2008 to 2010 for 16,000 people. They were asked, among other things, whether their doctors had ever told them they had Alzheimer’s disease. When the researchers then matched the respondents’ answers to their medical records, and the diagnostic codes that their doctors used to describe their care, only 45% of those who were billed for Alzheimer’s-related care were told by their doctors of their disease.

MORE New Research on Understanding Alzheimer’s

“What struck us was that physicians generally understand the positive benefits of disclosing the diagnosis, and agree with those benefits,” says Keith Fargo, director of scientific programs and outreach at the Association, who oversaw the analysis of the survey data. “But many still don’t do disclosure in their own practice.”

One of the few papers investigating the phenomenon of Alzheimer’s diagnoses found that as few as 36% of doctors said they usually told their patients if they had Alzheimer’s. The main reasons for the intentional omission? Fear of causing emotional distress in their patients and the lack of time and resources to fully explain what the diagnosis means. This was true of both primary care doctors as well as neurology specialists who have more expertise in brain-related disorders.

Dr. Robert Wergin, president of the American Academy of Family Physicians, advocates for transparency and honesty in disclosing diagnoses to his patients in his practice in Milford, Nebraska. But he understands why many physicians might be reluctant to use the word “Alzheimer’s” with their patients. “Labels are important,” he says. “When I label you and say you’ve got Alzheimer’s disease, then you’re likely to say, ‘Well that’s it for me, I better start looking for nursing homes.’”

MORE This Alzheimer’s Breakthrough Could Be a Game Changer

Alzheimer’s is a challenging diagnosis to make on several levels. First, it can only be definitively diagnosed at autopsy, when doctors can see the hallmark amyloid plaques and tangles that cause the gradual loss of memory and cognitive function. There is no blood test or brain scan that can conclusively tell doctors that a patient does or does not have the condition; while promising versions are being developed, it’s still a diagnosis that doctors make based on reports of the patients’ changing intellectual abilities and on psychiatric tests that aren’t specific for Alzheimer’s.

It’s also difficult to tell patients they likely have Alzheimer’s because there are currently no effective drugs for the disease. Medications can slow the effects of the cognitive decline, but nothing can stop or reverse the march of worsening symptoms. Wergin notes that once a patient is labeled with Alzheimer’s it could, at least before the Affordable Care Act, affect that patient’s ability to get insurance for nursing home care. “Once I label you, it’s in your chart. If an insurance company extracts your data, I’m not going to insure you because you are at higher risk of drawing on your coverage,” he says.

MORE New Test May Predict Alzheimer’s 10 Years Before Diagnosis

Wergin says that doctors may be over-anticipating the emotional distress that an Alzheimer’s diagnosis can bring. While the news is certainly difficult, most patients and their caregivers may already be aware that a neurodegenerative disease like Alzheimer’s may be present. And while there are no treatments that physicians can prescribe for their patients — at least not yet — Fargo and Beth Kallmyer, vice president of constituent services at the Association, note that it’s particularly important for Alzheimer’s patients and their families to know what to expect so they can begin planning. “There might not be a pill that slows the disease down or there might not be cures, but there are things people can do to impact their everyday quality of life,” says Kallmyer. “They can build a care team, and prepare advanced directives. And if a caregiver has knowledge of the disease, they can make things better in the day to day world of the person with the disease. If they don’t know about the diagnosis, they may not get that support.”

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But making doctors more comfortable with the diagnosis will take more structural changes in the way we deliver health care. The Alzheimer’s Association is supporting legislation that would reimburse doctors and their staff for a longer discussion about Alzheimer’s and how to plan for the disease. More medical schools are also including discussion about such planning in their curricula, as doctors in coming decades will be increasingly called upon to make this difficult disclosure.

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