TIME Cancer

Removing Ovaries During Breast Cancer Could Save Lives, New Research Says

For women with the BRCA1 mutation and breast cancer, a new study finds potential benefits from removing ovaries

In women who have both breast cancer and the BRCA1 mutation, having surgery to remove the ovaries can significantly lower their risk of dying from the disease, suggests a new study published in the journal JAMA Oncology.

Women with BRCA1 or BRCA2 genetic mutations have up to a 70% risk of getting breast cancer and a high risk for ovarian cancer. Like actress Angelina Jolie, these women will often consider undergoing preventative surgeries to remove the breasts and ovaries to keep that risk at bay. Now, a new study shows that for women who already have cancer and have a BRCA1 mutation, surgery to remove ovaries—called oophorectomy—could lower the risk of dying of breast cancer by 62%.

Women with BRCA mutations who already have breast cancer will often consider also removing their ovaries to prevent ovarian cancer or secondary breast cancer. Hormones from the ovaries are thought to stimulate the breast tissue and contribute to breast cancer risk.

The study looked at 676 women with stage I or II breast cancer and a BRCA1 or BRCA2 mutation. They were observed for up to 20 years after their diagnosis. Among the women, 345 underwent oophorectomy and 331 women kept their ovaries. At 20 years, the overall survival rate was around 77%—and the women who opted to remove their ovaries had a 56% lower risk for breast cancer death than women who didn’t. For women with the BRCA1 mutation, oophorectomy was associated with a 62% reduction in risk of death from breast cancer, but there was no significant association for women with the BRCA2 mutation. The study authors note that the number of women in the study with the BRCA2 mutation was also much lower than those who had BRCA1.

“The data presented here suggest that oophorectomy should be discussed with the patient shortly after diagnosis,” the study authors write. “We recommend that the operation be performed in the first year of treatment to maximize the benefit.”

Oophorectomy proved particularly beneficial for women with estrogen receptor–negative breast cancer. “It seems kind of counterintuitive,” says Dr. Robert DeBernardo, a gynecology-oncology surgeon at Cleveland Clinic’s Women’s Health Institute (who was not involved in the research). “The ovaries make the estrogen, and if we take it out, we expect to see less estrogen positive breast cancers, but we see a benefit from estrogen negative cancers. That very well may be because the ovary doesn’t just make estrogen or progesterone. It may also make some other things that we have not recognized.”

For women with BRCA mutations, DeBernardo says the study offers more insight into the risk and benefits of their surgical options. “All women with BRCA1 and BRCA2 mutations [will likely] see a specialist like myself to talk about the role of removing their ovaries and tubes,” says DeBernardo. “Now we have something else to discuss to make it easier to make a decision.”

TIME medicine

Hormone Treatments Raise Cancer Risk Even After They’re Stopped

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Estrogen and progestin therapy to treat menopause has led to controversial and confusing recommendations. But in the latest and longest term look at the data, experts say the risks of the hormones may last long after women stop taking them

Researchers admit that when it comes to hormone therapy — estrogen and progestin — to treat the symptoms of menopause for women, they don’t have a lot of consistent or convincing answers. They thought the medications could not only help menopause symptoms but also protect against heart disease, although some studies showed the added hormones could also raise risk of breast cancer. The resulting advice to women seeking answers about whether hormone therapy is for them has been anything but satisfying.

Now the scientists involved in the first large trial of hormone therapy, the Women’s Health Initiative (WHI), have continued to study those women who participated in the 1990s and found some surprising results. Reporting in the journal JAMA Oncology, they say that the risk of breast cancer for women taking the combination of estrogen and progestin remains the same seven to eight years after they stop the drugs than while they were taking them.

MORE: Hormone Replacement Therapy After Menopause: What Women Need to Know

The estrogen helps to maintain levels of that hormone as natural amounts start to drop during menopause, and the progestin protects the uterus from potential tumors arising from excess amounts of estrogen. They also found that for the quarter or so post-menopausal women who have had a hysterectomy, and can take estrogen alone, the hormone can lower their risk of breast cancer.

The WHI was created to study the health effects of hormone therapy on the millions of women taking them. Some small studies had suggested that the hormones could protect women from heart disease; women tend to have heart attacks about a decade or so later than men on average, and researchers believed some of that protection came from estrogen. But doctors were concerned about the known connection between estrogen and breast cancer, since during puberty estrogen contributes to breast tissue growth, and wanted to understand how the benefits for the heart matched up against the risks to the breast, so they enrolled more than 26,600 women aged 50 to 79 years in the WHI.

MORE: Estrogen After Menopause Lowers Breast Cancer Risk for Some Women

They intended to study them until 2005, but in 2002, they stopped the trial when it became clear that there was a group of women experiencing higher heart disease rates. It turned out that these were the women taking hormones, either the combination or estrogen alone.

MORE: The Truth About Hormones

The results completely changed menopause treatment, and led to a precipitous drop in the use of the medications; in the U.S., where about 40% of women turned to the hormones, only 15% did after most experts agreed that they should only be used in the short term, for about a year or so during and just after menopause. The assumption was that the benefits in lowering breast cancer risk would be similar — if women stopped taking the hormones, then their risk would decline.

That seemed to be true, at least for the first year or so after discontinuing the therapy. But in 2013, Dr. Rowan Chlebowski, an oncologist at Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, and one of the initial investigators on WHI, reported that the benefit didn’t hold for long. He found that if women who had previously been on estrogen and progestin therapy were studied for more than eight years, their risk of breast cancer started climbing back up, to levels that were on par with when they were taking the medications.

That finding, however, contradicted other results from studies. And to make matters more confusing, the women who had had a hysterectomy, and no longer had a uterus so could take estrogen alone, did not seem to experience the same increased risk of breast cancer. All of this data prompted Chlebowski to do a more detailed analysis of the WHI data on women who agreed to continue to participate years after they stopped taking the hormone therapy.

MORE: Making Sense of Hormone Therapy After Menopause

In the current study, it’s clear that the combination of estrogen and progestin increases breast cancer risk, he says. The drop in risk that occurs immediately after the therapy is stopped is likely due to the changing hormone environment. Any small or emerging tumors that were already present before hormone treatment started may eventually start growing again years later.

For women who have had a hysterectomy, taking estrogen alone does not increase breast cancer risk and may, according to the latest results, even provide some protection against the disease.

“It looks like hormones have longer term lingering effects,” says Chlebowski. “For estrogen and progestin together, we see an increase in risk even years after you stop. But for estrogen alone, it looks like the hormone may be more favorable in reducing breast cancer risk than we thought before. The estrogen alone findings are now quite compelling that we may had to call lit risk reduction.”

The results should stress the importance of defining what menopausal symptoms are, and how much they interfere with women’s daily lives. Most health groups now recommend short term hormone therapy, but it’s clear that the risks of breast cancer remain even after exposure. So doctors and patients need to weigh the relief of symptoms against the unhealthy legacy of taking these medications. “There is a little more risk than we thought with estrogen and progestin,” says Chlebowski. “But it’s always difficult to figure out how to categorize that risk. It’s different for each woman.”

TIME Cancer

New Genetic Test for Breast Cancer Would Be Cheaper and Easier

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Color Genomics Saliva test kit offered by Color Genomics

The test would cost just $249

A startup is developing a cheaper, easier way of determining whether women are genetically at risk for breast cancer, in a move that could revolutionize the way women are currently screened for the disease.

Currently, genetic testing for breast cancer risk is expensive and usually reserved for women who have a family history of the disease. But the startup Color Genomics is offering a saliva test that would cost only $249, about one-tenth the cost of many other genetic screens for breast cancer, the New York Times reports.

The saliva test analyzes BRCA1 and BRCA2, the two primary genes where mutations increase breast cancer risk, along with 17 other genes. Elad Gil, chief executive of Color Genomics, said he wants to “democratize access to genetic testing” and that the low cost of the saliva test means women could pay out of pocket if their insurance company did not cover the test.

Still, there are concerns. Some experts worry that the low cost of the test may not include a full analysis, and others raised concerns that greatly expanding the number of women tested could create confusion for those whose test results are unclear.

[The New York Times]

TIME Cancer

Most Women Should Not Get Yearly Mammograms, Group Says

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A U.S. panel of experts reaffirms its recommendations

Six years ago, the U.S. Preventive Services Task Force (USPSTF) caused a stir when it changed long-held breast-cancer-screening recommendations and advised women to wait until age 50 rather than 40 to start getting mammograms. The task force also said women should do it every other year, and women under age 50 were told that the choice to get mammograms at their age was an individual one.

In the intervening years, that’s become a less controversial opinion, partially because of growing evidence that too much screening can lead to anxiety-ridden false-positive results, overdiagnosis and overtreatment. On Monday, the USPSTF released its updated recommendations, which look very similar to the recommendations released in 2009.

The new draft guidelines suggest women ages 50 to 74 get a mammogram every two years and women ages 40 to 49 should make their own decision on whether to start screening in consultation with their doctors. The task force also concluded that there was not enough evidence to make a recommendation for or against mammograms for women ages 75 and older, 3-D mammography or additional screening besides mammograms for women who have dense breasts. The guidelines will now undergo a public commenting period, and you can send in comments here.

“In 2009, to suggest that mammography has limitations and that it has harms and that we need to look at the balance was not the way most people were thinking about it,” says Dr. Michael L. LeFevre, past chair of the USPSTF. “Much has been written about mammography in the last five years. I think people understand that it is a good test, it’s not a perfect test, and that there may be some significant harms associated with it.”

The task force added a nuance in the new guidelines that highlights which women might want to consider mammography more strongly, saying women in their 40s who have had a mother, sister or daughter with breast cancer are at a higher risk, and may benefit from mammography at a younger age than women who are at an average risk.

MORE: Diagnosed With Breast Cancer? Get a Second Opinion

In the past year, there’s been compelling evidence in support of the 3-D mammogram as an accurate — and perhaps better — screening tool. One June study showed 3-D mammograms can pick up more breast cancers and lead to fewer callbacks for more testing than 2-D mammography. LeFevre says that while it’s a promising technology, he doesn’t think there is enough evidence to prove if it will result in improved health. “We are going to have to see more than just detection. There have to be more studies that look specifically at the outcomes in order for us to be certain,” he says.

Despite the fact that the mammogram recommendations happened over six years ago, many doctors still insist on yearly mammograms for their patients over age 40. The American Cancer Society also continues to recommend that women age 40 and up get yearly mammograms.

“There are plenty of women in the position with people just telling them you need to have a mammogram every year. I am somewhat embarrassed to admit that is still going on,” says LeFevre. “On the other hand, I think women are being more proactive about their discussions of mammography, and I think that’s reflective of the environment change we are in.”

The task-force guidelines are intended for women ages 40 and up who do not show signs of breast cancer, have never had breast cancer and do not have risk factors like a genetic mutation that put them at higher risk. High-risk patients should consult with their doctor for an individualized screening plan.

“Mammography helps. We can reduce women’s likelihood of dying of breast cancer by undergoing some regular screening at some interval during certain ages. That’s a common theme across almost all organizations that look at this,” says LeFevre. “We think we should be doing it in a way where we maximize the balance of benefits and harms. That’s our topline message and that’s what I hope women hear.”

TIME Cancer

Breast Cancer May Increase 50% By 2030

By 2030, the number of breast cancer cases in the United States will be 50% higher than the number in 2011, according to new research from the National Cancer Institute.

In the new study, presented at the American Association for Cancer Research’s annual meeting, researchers used cancer surveillance data, census data and mathematical models to arrive at projections. Part of the reason the numbers are so high, they note, is because women are living longer. Another factor is the increase in screening that enables doctors to spot and diagnose more cases of in-situ tumors—very early stage growths that may not require treatment—as well as more invasive tumors.

MORE: This Mammogram Saves Lives and Money

The data comes amid concerns about the over-treatment of breast cancer. Last year, an analysis of women with stage 1 or stage 2 breast cancer in the Journal of the National Cancer Institute found little difference in survival rates 20 years after diagnosis between women who had an unaffected breast removed and those who did not.

“There’s certainly concern, especially in the older patients, about over-diagnosis of breast cancer, and that’s one of the reasons that screening mammography can become very controversial in older patients,” says Dr. Sharon Giordano, MPH, department chair of health services research at MD Anderson Cancer Center. (Giordano was not involved in the research.) “We don’t want to end up diagnosing and treating a disease that would never cause a problem during the person’s natural lifetime.”

Not all in-situ breast cancer progresses into a dangerous condition, Giordano explains. “One of the unanswered questions is, how do we identify the in-situ cancers that are the ones that go on and progress to a life-threatening illness, and which are the ones that we should be leaving alone and not subjecting people to invasive surgery and radiation for treatment?”

The researchers also teased out some more hopeful projections: that the number of estrogen-receptor negative (ER-negative) cancers, the kind that don’t need estrogen to grow and don’t typically respond to endocrine therapy, will drop from 17% in 2011 to 9% in 2030. That may be good news, since ER-positive breast cancers tend to grow slower and have better long-term survival rates. The reasons for the expected drop aren’t clear yet, the study authors say, but one contributing factor could be that women are having children later in life, and having a child young is a risk factor for ER-negative tumors.

“In sum, our results suggest that although breast cancer overall is going to increase, different subtypes of breast cancer are moving in different directions and on different trajectories,” said study author Philip S. Rosenberg, PhD, a senior investigator in cancer epidemiology and genetics at the National Cancer Institute, in a statement. “These distinct patterns within the overall breast cancer picture highlight key research opportunities that could inform smarter screening and kinder, gentler, and more effective treatment.”

TIME health

How Doctors of the Past Blamed Women for Breast Cancer

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Fine Art Photographic/Getty Images 'Motherhood' by Hector Caffieri, circa 1910

Breastfeeding, corsets and aging: the mysterious dangers of womanhood

History Today

 

 

 

This post is in partnership with History Today. The article below was originally published at HistoryToday.com.

‘I congratulate … [my fair countrywomen] on their present easy and elegant mode of dress’, wrote the surgeon James Nooth, in 1804, ‘free from the unnatural and dangerous pressure of stays.’ Nooth’s concern was not aesthetic. The danger he saw in restrictive bodices was cancer: ‘I have extirpated [removed] a great number of … tumours which originated from that absurdity.’

Breast cancer in the 19th century was a consistent, if mysterious, killer. It preoccupied many doctors, unable to state with any confidence the disease’s causes, characteristics or cures. While the orthodox medical profession in Britain were broadly agreed on cancer’s ultimate incurability, they were less uniform in their understanding of its origin. The disease was thought to develop from a range of harmful tendencies and events acting together. Both the essential biology of being female, as well as typically ‘feminine’ behaviors, were understood as causes of breast cancer.

Breastfeeding was a contentious topic at the end of the 18th century. An image of idealised motherhood emerged that infiltrated concepts of femininity: women were by nature loving, maternal and self-sacrificing. This ideology was expressed through changing social and political attitudes to breastfeeding and an outcry against wet-nursing across western Europe. In 1789 only 10 per cent of babies born in Paris were nursed by their own mothers; by 1801, this number had increased to half of all Parisian infants and two thirds of English babies.

Late 18th-century medical men were explicit about the associations between breastfeeding and breast cancer. In 1772, man-midwife William Rowley wrote: ‘When the vessels of the breasts are over-filled and the natural discharge through the nipple not encouraged … it lays the foundation of the cancer.’ Frances Burney – an aristocratic novelist who underwent a mastectomy in 1811 – attributed her disease to her inability to breastfeed properly: ‘They have made me wean my Child! … What that has cost me!’

Menstruation was seen as particularly hazardous. The surgeon Thomas Denman wrote: ‘Women who menstruate irregularly or with pain … are suspected to be more liable to Cancer than those who are regular, or who do not suffer at these times.’ However, their risk only increased after menopause. Denman considered ‘women about the time of the cessation of the menses’ most liable to cancer. Elderly women were blighted by a dual threat: their gender and their age. While surgeons insisted their theories were based on clinical observation, designating these various female-specific processes as causes of cancer supported their broader thoughts about female biology.

Eighteenth-century theory dictated that all diseases were explained by an imbalance in ‘humours’: black bile, yellow bile, blood and phlegm. Into the 19th century the insufficient drainage of various substances continued to be invoked as a cause of cancer; women’s ‘coldness and humidity’ made them particularly prone to disease. Menstruation was the primary mechanism by which the female body cleansed the system of black bile and its regularity was seen as central to a woman’s wellbeing. Certain situations in which the menses were disrupted or had been terminated were, therefore, especially dangerous: pregnancy, breastfeeding and menopause. Similarly, when the female body and its breasts were not used for their ‘correct’ purpose – childbearing and rearing – the risk of breast cancer increased.

The historian Marjo Kaartinen has noted that 18th-century theorists considered just ‘being female and having breasts’ a threat to a woman’s health. This way of thinking about female biology suggested that women were more likely to suffer from all cancers, not just cancer of the breast. Denman wrote: ‘It can hardly be doubted … that women are more liable to Cancer than men.’

This association between womanhood and disease and between breastfeeding, pregnancy, menopause and cancer is still part of our 21st-century understanding of breast cancer; that certain female-specific processes make you more or less likely to succumb to it. On its website, the breast cancer charity Breakthrough lists various ways you can reduce and increase your chances of disease. According to contemporary research, having children early and breastfeeding them reduces your risk. The later a woman begins her family the higher her risk is. The contraceptive pill, growing older and the menopause also increases your risk of breast cancer.

Drawing attention to such historical continuities questions the social and cultural environments that make certain medical assumptions possible. The causes of cancer suggested by Denman, Nooth and friends were informed by their understandings of female biology and female inferiority more generally. They were working within a school of thought that suggested any deviation from ‘appropriate’ womanhood could have hazardous consequences for a woman’s health. While the role of the historian might not be to deny the validity of 21st-century medical research, it is part of our remit to question cultural assumptions that continue to have some effect on both the conclusions of scientists and the way those conclusions are accepted by the broader public.

Agnes Arnold-Forster is a PhD candidate at King’s College London.

TIME celebrities

Rita Wilson Undergoes Double Mastectomy After Breast Cancer Diagnosis

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Mike Marsland—WireImage Rita Wilson attends the EE British Academy Film Awards 2014 at The Royal Opera House on February 16, 2014 in London, England. (Mike Marsland--WireImage)

Says husband Tom Hanks was by her side

Rita Wilson announced Tuesday that she has been diagnosed with breast cancer, and has undergone a double mastectomy and reconstructive surgery in order to fight the disease.

The actress revealed her diagnosis and treatment in a statement to People, and said the prognosis is good. “I am recovering and most importantly, expected to make a full recovery,” she said. “Why? Because I caught this early, have excellent doctors and because I got a second opinion.”

Wilson has recently appeared on Girls and The Good Wife and recently took a leave from the play A Fish in the Dark because of her health. Wilson said that her husband Tom Hanks was “by my side” through it all.

Read more at People.com

TIME Cancer

What to Do If You Have a Cancer Scare

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Don’t over-rely on Dr. Google

Late last month, Angelina Jolie announced that she had surgery to remove her ovaries and fallopian tubes with the aim of reducing her cancer risk. In her New York Times op-ed, she noted that she had recently had a cancer scare: Her doctor was concerned about some unusual blood test results, and sent her for further scans.

“I went through what I imagine thousands of other women have felt,” she wrote. “I told myself to stay calm, to be strong, and that I had no reason to think I wouldn’t live to see my children grow up and to meet my grandchildren.” Fortunately, the follow-up tests showed no signs of cancer.

Chances are at least once in your life you’ll have some sort of cancer scare—a strange mole that needs to be biopsied, a repeat mammogram, an abnormal Pap smear. In most cases, it’s nothing to worry about: “This happens every day in doctors’ offices all across America,” says Richard Wender, MD, chief cancer control officer at the American Cancer Society.

But it can be hard to stay calm when it’s actually happening to you. Here are five things to keep in mind:

Take a step back

Abnormal cancer screening results happen all the time: As many as 35% of women over the age of 40 report having had an abnormal Pap smear or mammogram at some point. “The most common resolution of that abnormal test is finding that you don’t have cancer,” Dr. Wender says.

Remember, the reason these tests have such high cancer-detection rates is because they screen women for any small thing—like calcification on a mammogram—that could potentially indicate cancer.

Read more: 19 Medical Tests Everyone Needs

Make sure you’re hearing your doctor

“Sometimes, when I explain a screening test result to a patient, I can sense that she’s so anxious she’s not processing what I’m saying,” says Dr. Wender. Research shows that almost half of the details remembered from a doctor’s visit are incorrect.

Don’t rely on your memory, especially at an emotional time like this. Either jot down exactly what the doctor says (and don’t be afraid to have them repeat it) or make sure a friend or family member is either in the office with you or on the phone when you speak to your physician.

Read more: What Doctors Don’t Tell You (But Should)

Try not to stress about additional waiting

If suspicious mammogram findings mean your doctor recommends a biopsy, don’t worry if it’s several weeks away. “Waiting three weeks will not change the prognosis and outcome at all if it does turn out to be cancer,” says Dr. Wender.

You also shouldn’t necessarily be alarmed if your doctor doesn’t recommend more invasive testing—such as a colposcopy or biopsy—and instead suggests simply returning for follow-up screening in six months.

“Oftentimes a doctor or technician will see something that doesn’t look like cancer, but they just want to double check it in a few months to be safe,” explains Dr. Wender.

Read more: A Complete Guide to Breast Cancer Screening

Don’t go overboard on Dr. Google

Sometimes, Google can be reassuring: “If you type in ‘abnormal pap smear’ or ‘abnormal mammogram’ or even ‘suspicious mole,’ you’ll see how common the false positive rate is,” says Dr. Wender.

But other times, you’ll just scare yourself unnecessarily. “I had a patient recently who had some tests come back suggestive of a very lethal form of uterine cancer,” recalls Dr. Wender. “When I called her, I said, ‘Don’t research it on the Internet. Just don’t do it.’ She didn’t—and six weeks later, when we learned after a surgical biopsy that the results were benign, she was tremendously relieved.”

Read more: 9 Scary Symptoms You Don’t Need to Worry About

Ask lots of questions

If you’ve got fears, articulate them. “If you ask your doctor what the likelihood is that your test result indicates cancer, they may not have exact numbers but they should be able to respond to you in a general way, which is usually reassuring,” says Dr. Wender.

And if they brush off your worries, or refuse to answer you, it may be time to seek out another doctor—or at least get a second opinion.

Read more: How Good Is Your Doctor?

This article originally appeared on Health.com.

Read next: This Is What Getting Cancer Looks Like on Social Media

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MONEY Health Care

Who Covers the Costs of Preventive Surgery Like Angelina Jolie’s

Actress Angelina Jolie
Matt Sayles—Invision/AP

Faced with a genetic predisposition to cancer, Angelina Jolie opted for a preventive surgery to remove her ovaries and fallopian tubes. But can other women afford to do the same?

This week, actress and director Angelina Jolie took to the New York Times to announce a big decision: She had her ovaries and fallopian tubes surgically removed, a preventive measure meant to decrease her risk of ovarian and breast cancer. This surgery followed her preventive double mastectomy in 2013.

After losing her mother, grandmother, and aunt to cancer, Jolie underwent genetic testing and learned that she had a mutation in one of her BRCA genes, a tumor-suppressor gene. That means she too has an increased risk of developing breast cancer and ovarian cancer.

“I feel feminine, and grounded in the choices I am making for myself and my family,” Jolie wrote. “I know my children will never have to say, ‘Mom died of ovarian cancer.'”

The good news: If you share Jolie’s predisposition to cancer, the same treatment options are probably available to you. Most insurers will cover preventive surgery for women with a BRCA mutation, says Lisa Schlager, vice president for community affairs and public policy at Facing Our Risk of Cancer Empowered (FORCE), a nonprofit organization devoted to hereditary breast and ovarian cancer. (Generally, Medicare and Medicaid aren’t as generous, Schlager says.)

That’s been true for a long time—a 2001 study found that 97% of preventive surgeries for women with BRCA mutations were fully covered by insurance (except for deductibles and copays).

The surgery can be costly. According to HealthSparq, a health care costs transparency firm, the average national cost for the surgical removal of the ovaries and fallopian tubes is $12,381.

That’s the average insurer-negotiated price, based on actual claims data from 67 health plans. In other words, that’s the average price insurers have agreed to pay hospitals and health providers for the procedure. You can expect to pay a smaller portion of that cost, depending on your health plan’s deductible, co-pays and co-insurance.

Today, the average deductible for Americans with single, employer-subsidized health coverage is $1,217, which means most need to pay more than a grand out-of-pocket before insurance begins to cover the bulk of their costs, according to the Kaiser Family Foundation.

“It really depends on your insurance and your deductible,” Schlager says. “Some people have a very high deductible, and we’re referring them to services that provide financial assistance.”

Prices can also vary significantly by region. According to HealthSparq, the average cost of the procedure is $8,693 in Maryland, but $20,763 in San Francisco, a $12,070 price gap.

Market Average Cost
San Francisco – San Jose CA $20,763.06
San Diego CA $16,508.06
Miami – Fort Lauderdale FL $16,441.37
LA – Orange County CA $16,378.38
Houston TX $14,687.49
Austin – San Antonio TX $13,617.29
New York City – White Plains NY $13,591.84
Dallas – Fort Worth TX $13,404.92
New Orleans LA $12,049.43
Cinncinati – Dayton OH $11,987.74
Columbus OH $11,335.80
Albany NY $9,559.04
Washington DC – Arlington VA $8,747.73
Maryland $8,692.77
AVERAGE NATIONAL $12,380.55
PRICE GAP $12,070.29

But generally, insurers will cover the surgery. After all, “the surgeries are less expensive to the private insurers than if you were to get cancer,” Schlager says.

How do you know if you’re at risk? According to guidelines from the National Comprehensive Cancer Network, you should get screened for genetic abnormalities if any of your family members develop ovarian or fallopian tube cancer, breast cancer in both breasts, breast and ovarian cancer, breast cancer before age 50, male breast cancer, or other signs of hereditary breast-ovarian cancer syndrome. You should also get tested if more than one blood relative on the same side of your family has breast, ovarian, fallopian tube, prostate, pancreatic, or melanoma cancer. The U.S. Preventive Services Task Force, which helps implement the Affordable Care Act, made similar recommendations.

Schlager says the cost of genetic testing has “dropped substantially” in recent years, to between $1,500 and $4,000. Most insurers will cover genetic testing if you meet the national guidelines, but if your insurer refuses, some labs have financial assistance programs to limit your out-of-pocket cost to about $100, Schlager says.

Then you should meet with a genetic counselor. The Affordable Care Act mandates that health insurers cover genetic counseling with no cost-sharing if you have an increased risk of breast or ovarian cancer. That is to say, genetic counseling is a women’s preventive service that should be free to you, like birth control.

Jolie was quick to note that her choice isn’t the answer for everyone. “A positive BRCA test does not mean a leap to surgery,” Jolie wrote. “I have spoken to many doctors, surgeons and naturopaths. There are other options.”

A genetic counselor should help you understand the implications of preventive surgery and consider other less invasive—but less effective—measures, like increased cancer screenings. “It’s a very personal decision, and every family is different,” Schlager says. “Your first step is to talk to your doctor.”

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.”

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