Angelina Jolie's mother had breast cancer and died of ovarian cancer, and her maternal grandmother also had ovarian cancer — strong evidence of an inherited, genetic risk that led the actress to have both of her healthy breasts removed to try to avoid the same fate, her doctor says.

Jolie, 37, revealed on Tuesday that she carries a defective BRCA1 gene that puts her at high risk of developing breast and ovarian cancer. She had mastectomies in February followed by reconstruction with implants in April, Dr. Kristi Funk said in an interview with The Associated Press.

Funk treated Jolie at the Pink Lotus Breast Center in Beverly Hills and detailed her care on the center's website. She would not disclose when Jolie learned she carried the faulty gene, which gives a woman up to an 87 percent lifetime risk of developing breast cancer and up to a 54 percent chance of ovarian cancer.

"This family history would certainly meet any insurance carrier's criteria to cover genetic testing," Funk wrote.

It is unclear whether Jolie will have her ovaries removed, although she wrote in her op-ed piece in the New York Times that she "started with the breasts" because they posed the highest cancer risk.

Removing the ovaries is often advised for women with such gene mutations, said Dr. Charis Eng, a medical geneticist and cancer specialist at the Cleveland Clinic who had no role in Jolie's care.

"We usually say 'try to have your kids'" and then have your ovaries removed by age 40, Eng said. It's not possible to remove every speck of breast tissue, but removing the breasts and ovaries leaves very little behind that could develop cancer, so it dramatically lowers a woman's risks, she said.

On the surgery center's website, Funk described Jolie's three operations, which were done through the crease underneath each breast. Jolie's partner, actor Brad Pitt, "was on hand to greet her as soon as she came around from the anesthetic, as he was during each of the operations," Funk wrote.

On Feb. 2, Jolie had a procedure aimed at preserving the nipples, which usually are removed when a mastectomy is done to treat breast cancer. Half of the skin is lifted from the surface of the breast tissue and a small disc of tissue is taken to be checked for cancer.

The tissue proved healthy and on Feb. 16 she had the two mastectomies. Doctors also took an unusual step: injecting dye to determine which lymph nodes in her arms were draining fluid from the breasts. Those nodes would be most likely to contain cancer if any turned out to be lurking in the breast, Funk explained.

When a preventive mastectomy is done, "there's a 2 to 8 percent chance" of finding cancer, even though there was no indication of cancer beforehand, Funk said. Stitches or a tiny clip can be placed to show the location of these key "sentinel" lymph nodes in case Jolie ever were to develop cancer in the future and those nodes would need to be checked again.

Also during this operation, doctors placed a tissue expander, a balloon-like device that is slowly inflated with saline to stretch the skin and make room for a permanent implant. Even though the implant could have been done at the time of the mastectomy, Jolie chose the two-step procedure to optimize the final cosmetic appearance.

Four days after her mastectomies, "I was pleased to find her not only in good spirits with bountiful energy, but with two walls in her house covered with freshly assembled storyboards for the next project she is directing," Funk wrote on the website.

On April 27, doctors did her reconstruction, using a newer teardrop-shaped implant plus sheets of cadaver skin, which "creates like a sling under the implant" to give a more natural look, Funk said.

The website describes how women with gene mutations that raise their risk for cancer are monitored starting at age 18, but Funk said she could not disclose when Jolie was tested and learned she had the BRCA1 gene. About 5 percent to 10 percent of breast cancers and about 15 percent of ovarian cancers are thought to be due to BRCA gene mutations.

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The biggest thing in operating rooms these days is a million-dollar, multi-armed robot named da Vinci, used in nearly 400,000 surgical procedures nationwide last year — triple the number just four years earlier.

But now the high-tech helper is under scrutiny over reports of problems, including several deaths that may be linked with it and the high cost of using the robotic system.

There also have been a few disturbing incidents: a robotic hand that wouldn't let go of tissue grasped during surgery and a robotic arm hitting a patient in the face as she lay on the operating table.

Is it time to curb the robot enthusiasm?

Some doctors say yes, concerned that the "wow" factor and heavy marketing have boosted use. They argue that there is not enough robust research showing that robotic surgery is at least as good or better than conventional surgery.

Many U.S. hospitals promote robotic surgery in patient brochures, online and even on highway billboards. Their aim is partly to attract business that helps pay for the costly robot.

The da Vinci is used for operations that include removing prostates, gallbladders and wombs, repairing heart valves, shrinking stomachs and transplanting organs. Its use has increased worldwide, but the system is most popular in the United States.

"We are at the tip of the iceberg. What we thought was impossible 10 years ago is now commonplace," said Dr. Michael Stifelman, robotic surgery chief at New York University's Langone Medical Center.

For surgeons, who control the robot while sitting at a computer screen rather than standing over the patient, these operations can be less tiring. Plus robot hands don't shake. Advocates say patients sometimes have less bleeding and often are sent home sooner than with conventional laparoscopic surgery and operations involving large incisions.

But the Food and Drug Administration is looking into a spike in reported problems during robotic procedures. Earlier this year, the FDA began a survey of surgeons using the robotic system. The agency conducts such surveys of devices routinely, but FDA spokeswoman Synim Rivers said the reason now "is the increase in number of reports received" about da Vinci.

Reports filed since early last year include at least five deaths.

Whether there truly are more problems recently is uncertain. Rivers said she couldn't quantify the increase and that it may simply reflect more awareness among doctors and hospitals about the need to report problems. Doctors aren't required to report such things; device makers and hospitals are.

It could also reflect wider use. Last year there were 367,000 robot operations versus 114,000 in 2008, according to da Vinci's maker, Intuitive Surgical Inc. of Sunnyvale, Calif.

Da Vinci is the company's only product, and it's the only robotic system cleared for soft-tissue surgery by the FDA. There are other robotic devices approved for neurosurgery and orthopedics, among other things.

A search for the company's name in an FDA database of reported problems related to medical devices brings up 500 reports since Jan. 1, 2012. Many of those came from Intuitive Surgical. The reports include incidents that happened several years ago and some are duplicates. There's also no proof any of the problems were caused by the robot, and many didn't injure patients. Reports filed this year include:

— A woman who died during a 2012 hysterectomy when the surgeon-controlled robot accidentally nicked a blood vessel.

— A Chicago man who died in 2007 after spleen surgery.

— A New York man whose colon was allegedly perforated during prostate surgery. Da Vinci's maker filed that report after seeing a newspaper article about it and said the doctor's office declined to provide additional information.

— A robotic arm that wouldn't let go of tissue grasped during colorectal surgery on Jan. 14. "We had to do a total system shutdown to get the grasper to open its jaws," said the report filed by the hospital. The report said the patient was not injured.

— A robotic arm hit a patient in the face during a hysterectomy. The company filed that report, and said it is unknown if the patient was injured but that the surgeon decided to switch to an open, more invasive operation instead.

Intuitive Surgical filed all but one of those reports.

Complications can occur with any type of surgery, and so far it's unclear if they are more common in robotic operations, but that's part of what the FDA is trying to find out.

Intuitive Surgical disputes there's been a true increase in problems and says the rise reflects a change it made last year in the way it reports problems.

The da Vinci system "has an excellent safety record with over 1.5 million surgeries performed globally, and total adverse event rates have remained low and in line with historical trends," said company spokeswoman Angela Wonson.

But an upcoming research paper suggests that problems linked with robotic surgery are underreported. They include cases with "catastrophic complications," said Dr. Martin Makary, a Johns Hopkins surgeon who co-authored the paper.

"The rapid adoption of robotic surgery ... has been done by and large without the proper evaluation," Makary said.

The da Vinci system, on the market since 2000, includes a three- or four-armed robot that surgeons operate with hand controls at a computer system located several feet away from the patient. They see inside the patient's body through a tiny video camera attached to one of the long robot arms. The other arms are tipped with tiny surgical instruments.

Robotic operations are similar to conventional laparoscopy, or "keyhole" surgery, which involves small incisions and camera-tipped instruments controlled by the surgeon's hands, not a robot.

Almost 1,400 U.S. hospitals — nearly 1 out of 4 — have at least one da Vinci system. Each one costs about $1.45 million, plus $100,000 or more a year in service agreements.

The most common robotic operations include prostate removal. Aabout 85 percent of these operations in the U.S. are done with the robot. Da Vinci also is often used for hysterectomies, Wonson said.

Makary says there's no justification for the skyrocketing increase in robotic surgery, which he attributes to aggressive advertising by the manufacturer and hospitals seeking more patients.

He led a study published in 2011 that found 4 in 10 U.S. hospitals promoted robotic surgery on their websites, often using wording provided by the manufacturer. Some of the claims exaggerated the benefits or had misleading, unproven claims, the study said.

Stifelman, the Langone surgeon, said it makes sense for hospitals to promote robotic surgery and other new technology to, but that it doesn't mean that it's the right option for all patients.

"It's going to be the responsibility of the surgeon ... to make sure the patient knows there are lots of options," and to discuss the risks and benefits, he said.

His hospital expects to do more than 1,200 robotic procedures this year, versus just 175 in 2008.

For a few select procedures that require operating in small, hard-to-reach areas, robotic surgery may offer advantages over conventional methods, Makary said. Those procedures include head and neck cancer surgery and rectal surgery.

Some surgeons say the robotic method also has advantages for weight-loss surgery on extremely obese patients, whose girth can make hands-on surgery challenging.

"At the console, the operation can be performed effectively and precisely, translating to superior quality," said Dr. Subhashini Ayloo, a surgeon at the University of Illinois Hospital & Health Sciences System in Chicago.

Ayloo, who uses the da Vinci robot, began a study last year on the effectiveness of doing robotic obesity surgery in patients who need a kidney transplant. Some hospitals won't do transplants on obese patients with kidney failure because it can be risky. In the study, robotic stomach-shrinking surgery and kidney transplants are done simultaneously. Patients who get both will be compared with a control group getting only robotic kidney transplants.

"We don't know the results, but so far it's looking good," Ayloo said.

Aidee Diaz of Chicago was the first patient and was taken aback when told the dual operation would be done robotically.

"At first you would get scared. Everybody says, 'A robot?' But in the long run that robot does a lot of miracles," said Diaz, 36.

She has had no complications since her operation last July, has lost 100 pounds and says her new kidney is working well.

Lawsuits in cases that didn't turn out so well often cite inadequate surgeon training with the robot. These include a malpractice case that ended last year with a $7.5 million jury award for the family of Juan Fernandez, a Chicago man who died in 2007 after robotic spleen surgery. The lawsuit claimed Fernandez's surgeons accidentally punctured part of his intestines, leading to a fatal infection.

The surgeons argued that Fernandez had a health condition that caused the intestinal damage, but it was the first robot operation for one of the doctors and using the device was overkill for an ordinarily straightforward surgery, said Fernandez's attorney, Ted McNabola.

McNabola said an expert witness told him it was like "using an 18-wheeler to go the market to get a quart of milk."

Company spokesman Geoff Curtis said Intuitive Surgical has physician-educators and other trainers who teach surgeons how to use the robot. But they don't train them how to do specific procedures robotically, he said, and that it's up to hospitals and surgeons to decide "if and when a surgeon is ready to perform robotic cases."

A 2010 New England Journal of Medicine essay by a doctor and a health policy analyst said surgeons must do at least 150 procedures to become adept at using the robotic system. But there is no expert consensus on how much training is needed.

New Jersey banker Alexis Grattan did a lot of online research before her gallbladder was removed last month at Hackensack University Medical Center. She said the surgeon's many years of experience with robotic operations was an important factor. She also had heard that the surgeon was among the first to do the robotic operation with just one small incision in the belly button, instead of four cuts in conventional keyhole surgery.

"I'm 33, and for the rest of my life I'm going to be looking at those scars," she said.

The operation went smoothly. Grattan was back at work a week later.

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You might not want to rush into knee surgery. Physical therapy can be just as good for a common injury and at far less cost and risk, the most rigorous study to compare these treatments concludes.

Therapy didn't always help and some people wound up having surgery for the problem, called a torn meniscus. But those who stuck with therapy had improved as much six months and one year later as those who had arthroscopic surgery right away, researchers found.

"Both are very good choices. It would be quite reasonable to try physical therapy first because the chances are quite good that you'll do quite well," said one study leader, Dr. Jeffrey Katz, a joint specialist at Brigham and Women's Hospital and Harvard Medical School.

He was to discuss the study Tuesday at an American Academy of Orthopaedic Surgeons conference in Chicago. Results were published online by the New England Journal of Medicine.

A meniscus is one of the crescent-shaped cartilage discs that cushion the knee. About one-third of people over 50 have a tear in one, and arthritis makes this more likely. Usually the tear doesn't cause symptoms but it can be painful.

When that happens, it's tough to tell if the pain is from the tear or the arthritis — or whether surgery is needed or will help. Knee surgery for a torn meniscus is done about half a million times each year in the U.S.

The new federally funded study compared surgery with a less drastic option. Researchers at seven major universities and orthopedic surgery centers around the U.S. assigned 351 people with arthritis and meniscus tears to get either surgery or physical therapy. The therapy was nine sessions on average plus exercises to do at home, which experts say is key to success.

After six months, both groups had similar rates of functional improvement. Pain scores also were similar.

Thirty percent of patients assigned to physical therapy wound up having surgery before the six months was up, often because they felt therapy wasn't helping them. Yet they ended up the same as those who got surgery right away, as well as the rest of the physical therapy group who stuck with it and averted an operation.

"There are patients who would like to get better in a 'fix me' approach" and surgery may be best for them, said Elena Losina, another study leader from Brigham and Women's Hospital.

However, an Australian preventive medicine expert contends that the study's results should change practice. Therapy "is a reasonable first strategy, with surgery reserved for the minority who don't have improvement," Rachelle Buchbinder of Monash University in Melbourne wrote in a commentary in the medical journal.

As it is now, "millions of people are being exposed to potential risks associated with a treatment that may or may not offer specific benefit, and the costs are substantial," she wrote.

Surgery costs about $5,000, compared with $1,000 to $2,000 for a typical course of physical therapy, Katz said.

One study participant — Bob O'Keefe, 68, of suburban Boston — was glad to avoid surgery for his meniscus injury three years ago.

"I felt better within two weeks" on physical therapy, he said. "My knee is virtually normal today."  He still does the recommended exercises several times a week.

Robert Dvorkin had both treatments for injuries on each knee several years apart. Dvorkin, 56, director of operations at the Coalition for the Homeless in New York City, had surgery followed by physical therapy for a tear in his right knee and said it was months before he felt no pain.

Then, several years ago, he hurt his left knee while exercising. "I had been doing some stretching and doing some push-ups and I just felt it go 'pop.'" he recalls. "I was limping. It was extremely painful."

An imaging test showed a less severe tear and a different surgeon recommended physical therapy. Dvorkin said it worked like a charm — he avoided surgery and recovered faster than from his first injury. The treatment involved two to three hour-long sessions a week, including strengthening exercises, balancing and massage. He said the sessions weren't that painful and his knee felt better after each one.

"Within a month I was healed," Dvorkin said. "I was completely back to normal."

In a stunning example of when treatment might be worse than the disease, a large review of Medicare records finds that older people with small kidney tumors were much less likely to die over the next five years if doctors monitored them instead of operating right away.

Even though nearly all of these tumors turned out to be cancer, they rarely proved fatal. And surgery roughly doubled patients' risk of developing heart problems or dying of other causes, doctors found.

After five years, 24 percent of those who had surgery had died, compared to only 13 percent of those who chose monitoring. Just 3 percent of people in each group died of kidney cancer.

The study only involved people 66 and older, but half of all kidney cancers occur in this age group. Younger people with longer life expectancies should still be offered surgery, doctors stressed.

The study also was observational - not an experiment where some people were given surgery and others were monitored, so it cannot prove which approach is best. Yet it offers a real-world look at how more than 7,000 Medicare patients with kidney tumors fared. Surgery is the standard treatment now.

"I think it should change care" and that older patients should be told "that they don't necessarily need to have the kidney tumor removed," said Dr. William Huang of New York University Langone Medical Center. "If the treatment doesn't improve cancer outcomes, then we should consider leaving them alone."

He led the study and will give results at a medical meeting in Orlando, Fla., later this week. The research was discussed Tuesday in a telephone news conference sponsored by the American Society of Clinical Oncology and two other cancer groups.

In the United States, about 65,000 new cases of kidney cancer and 13,700 deaths from the disease are expected this year. Two-thirds of cases are diagnosed at the local stage, when five-year survival is more than 90 percent.

However, most kidney tumors these days are found not because they cause symptoms, but are spotted by accident when people are having an X-ray or other imaging test for something else, like back trouble or chest pain.

Cancer experts increasingly question the need to treat certain slow-growing cancers that are not causing symptoms - prostate cancer in particular. Researchers wanted to know how life-threatening small kidney tumors were, especially in older people most likely to suffer complications from surgery.

They used federal cancer registries and Medicare records from 2000 to 2007 to find 8,317 people 66 and older with kidney tumors less than 1.5 inches wide.

Cancer was confirmed in 7,148 of them. About three-quarters of them had surgery and the rest chose to be monitored with periodic imaging tests.

After five years, 1,536 had died, including 191 of kidney cancer. For every 100 patients who chose monitoring, 11 more were alive at the five-year mark compared to the surgery group. Only 6 percent of those who chose monitoring eventually had surgery.

Furthermore, 27 percent of the surgery group but only 13 percent of the monitoring group developed a cardiovascular problem such as a heart attack, heart disease or stroke. These problems were more likely if doctors removed the entire kidney instead of just a part of it.

The results may help doctors persuade more patients to give monitoring a chance, said a cancer specialist with no role in the research, Dr. Bruce Roth of Washington University in St. Louis.

Some patients with any abnormality "can't sleep at night until something's done about it," he said. Doctors need to say, "We're not sticking our head in the sand, we're going to follow this" and can operate if it gets worse.

One of Huang's patients - 81-year-old Rhona Landorf, who lives in New York City - needed little persuasion.

"I was very happy not to have to be operated on," she said. "He said it's very slow growing and that having an operation would be worse for me than the cancer."

Landorf said her father had been a doctor, and she trusts her doctors' advice. Does she think about her tumor? "Not at all," she said.

Jeff Fitlow / Rice University

A team of Rice University engineering seniors created a device to lift the weight from the abdomens of obese patients undergoing surgery. The R-Aides device uses suction cups hooked to a vacuum to help patients under light sedation breathe.

At first it sounds like the start of one of those offensive “fat” jokes obese people hate so much: “How fat was he? So fat the surgeons need suction cups to lift his belly.”

But this is no joke. A team of Rice University bioengineering students, responding to an urgent request from heart surgeon Mehdi Razavi, has developed a device that can lift the abdomen of an obese patient undergoing surgery so the patient can breathe.

Razavi, an electrophysiologist who specializes in implanting pacemakers and performs heart catheterizations, often places his patients under “conscious sedation,” a light anesthesia, because if the patient were simply knocked out, with a tube down his or her throat, and a machine doing the breathing, there’d be a greater risk of complications. But during one surgery on an obese man, Razavi realized his patient was snoring and having trouble breathing. The man’s oxygen levels were dropping.

That’s because the man was struggling against his own abdominal fat.

“It’s like putting a suitcase on the belly,” Razavi said. “It presses down and the belly has to go somewhere, so it pushes against the lungs, and if you try to take a deep breath, the lungs cannot expand.” The problem could become so severe, the doctor would have to stop the surgery.

The device the students designed uses suction cups hooked to a horizontal beam hovering above the abdomen. The cups are attached to the skin – there is a slight chance of bruising, student Marisa Prevost said – and a vacuum pump. Activating the device slightly raises the abdomen so the fat is out of the way.

When Razavi first approached the students for help, they were incredulous. “When we first heard about it, we were, like, ‘Huh? What?’” Prevost said. “We thought, that’s kind of weird.”

Now though, they’re intimately aware of how America’s obesity crisis is affecting medical practice in dozens of ways.

As of 2010, more than 35 percent of U.S. adults were obese. By 2030, the U.S. obesity rate is projected to rise to 42 percent. Obesity puts people at much greater risk for all sorts of medical problems, so they wind up in doctors’ offices and in hospitals more often than optimal weight people.

Medicine is struggling to make accommodations. Doctors often check blood pressure using cuffs meant for thighs, Razavi said. Surgical tools have to be enlarged in order to reach through layers of fat. Obese patients require higher doses of radiation during imaging tests like CT scans. “And that means if I’m doing the procedure, I am getting higher doses of radiation, too,” Razavi pointed out.

Some patients won’t fit into MRI scanners. Surgical tables have been redesigned to handle patients weighing up to 450 pounds. Needles for injections have made been longer so they can penetrate fat layers and reach muscles. Even lab tests results have to be interpreted differently.

For surgeries, Razavi said, “the ultimate compromise is that if the patient is really obese, you either do it under general anesthesia, or don’t offer it at all. It’s a judgment call,” he said. “When you tailor therapy to each patient, sometimes the risks outweigh the benefits.”

Brian Alexander is co-author, with Larry Young PhD., of "The Chemistry Between Us: Love Sex and the Science of Attraction,"  to be published Sept. 13.

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By  Rachael Rettner
MyHealthNewsDaily

While being trim is generally good for your health, it may actually raise the risk of death after surgery, recent research suggests.

In one study, slender people with a body mass index (BMI) of 23 or less were 40 percent more likely to die within a month of a surgical procedure, compared with those who were overweight, with a BMI between 26 and 29, the researchers said.

The results held even after the researchers took into account the condition the patient had that required surgery, and the risk of death associated with that surgery.

That study is published in the March issue of the journal Archives of Surgery.

The findings agree with those of several other recent studies. In a study published last week in the Journal of Cardiothoracic and Vascular Anesthesia, 20 percent of underweight patients who had coronary artery bypass surgery died in the hospital, compared with 3 percent of obese patients (though the researchers noted far fewer patients in the study were underweight).

And in a study published in February in the journal Colorectal Disease, low BMI was a risk factor for dying after colon surgery.

Low BMI should be recognized as an important risk factor for death following surgery, study researcher George Stukenborg, of the University of Virginia’s School of Medicine, said in an interview with MyHealthNewsDaily in November. Doctors should take into account thinness when planning a patient's care after surgery, and should tell thin patients about their increased risk of death, Stukenborg said.

Death after surgery
In their study, Stukenborg and colleagues analyzed information from more than 189,500 patients from 183 medical centers who underwent surgery between 2005 and 2006.

The researchers divided patients into five groups based on BMI. They calculated the risk of death for each group, as compared with the risk of death for those in the middle group (who had a BMI between 26.3 and 29.7).

About 3,200 patients died within 30 days of surgery. Among those with a BMI of 23.1 or less, 2.8 percent died within 30 days, whereas 1.5 percent of patients with a BMI between 26.3 and 29.7 died.

There was no difference in the risk of death between patients who were overweight, and patients who were obese or very obese, the researchers found.

Why the link?
This study cannot tell us why thin people are at an increased risk of death after surgery, Stukenborg said. One idea is that these patients may be more frail, or may have recently experienced weight loss, Stukenborg said.

In the study published last week, underweight patients were at higher risk of intestinal bleeding, pneumonia, a prolonged stay in the intensive care unit and need for a blood transfusion compared with those who were obese.

People with a BMI of under 18.5 are generally considered underweight, and in the studies, they were included with patients who had BMIs between 19 and 24, who were of normal weight.

People who fall along the extremes of the weight spectrum, both underweight and morbidly obese, are at increased risk for complications after surgery, said Dr. Nestor de la Cruz-Munoz, chief of bariatric surgery, University of Miami School of Medicine. Underweight people likely represent a sicker population with underlying medical conditions, de la Cruz-Munoz said.

"As soon as you drop below your ideal weight, you get into a group of people who are malnourished," and not well in general, de la Cruz-Munoz said. People in this population may not have adequate levels of protein in their bodies to properly heal in areas that have been operated on, he said.

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