It was an extraordinarily public declaration of an incredibly private experience. But when Angelina Jolie took to the comment pages of the New York Times to declare that she had undergone a double mastectomy, she spearheaded a new awareness of gene testing as a guard against the possibility of breast cancer.
Doctors and medical experts specialising in the disease welcomed her announcement as a way of raising the profile of the test, but warned that for most women it would not be relevant as the gene mutation she has inherited is so rare.
In her account, published on Wednesday, Jolie appealed for greater access for gene testing and lifesaving preventive treatment and encourages women to explore their options.
The actor has a defective gene, BRCA1, which doctors told her increased her risk of developing breast cancer to 87%; it also increased her risk of ovarian cancer.
The surgery, which began in February, had reduced Jolie's risk of breast cancer to less than 5%. "I can tell my children that they don't need to fear they will lose me to breast cancer," she wrote. "It is reassuring that they see nothing that makes them uncomfortable. They can see my small scars and that's it. Everything else is just Mommy, the same as she always was. And they know that I love them and will do anything to be with them as long as I can.
"On a personal note, I do not feel any less of a woman. I feel empowered that I made a strong choice that in no way diminishes my femininity."
Jolie wrote of losing her own mother to cancer, at the age of 56, after a decade-long fight: "She held out long enough to meet the first of her grandchildren and to hold them in her arms. But my other children will never have the chance to know her and experience how loving and gracious she was." Marcheline Bertrand, mother of Angelina Jolie, passed away from ovarian cancer at 56, following a 10-year battle with the disease.
The 37-year-old, who has six children – three adopted and three with Brad Pitt, who was by her side for "every minute of the surgeries" – finished three months of medical procedures on 27 April. She said she first had "nipple delay" to maximise the chances of saving her nipples, before breast tissue removal and, nine weeks later, reconstruction. Husband Brad Pitt was by her side for "every minute of the surgeries"
Jolie wrote: "I choose not to keep my story private because there are many women who do not know that they might be living under the shadow of cancer. Life comes with many challenges. The ones that should not scare us are the ones we can take on and take control of."
Wendy Watson, who founded the UK's National Hereditary Breast Cancer Helpline, welcomed Jolie's decision to write publicly about her operation. "It is excellent, because it is the highest profile you can get for it," she said. "It raises the profile for other women to look to if they have a family history and would benefit from being screened more frequently, or having surgery or having a genetic test."
The UK foreign secretary, William Hague, who visited refugee camps in the Democratic Republic of the Congo with Jolie in March, said she would be "an inspiration to many". Hague said: "She gave no sign that she was undergoing such treatment and I think she's a very brave lady, not only to carry on with her work so well during such treatment, but also to write about it now and talk about it."
But Dr Marisa Weiss, who runs an online advice and information service on breast cancer based in Ardmore, Pennsylvania, pointed out that only 29% of cancers in women start in the breast and within that group only 5% to 10% of women are carriers of high-risk single genes such as the one for which Jolie tested positive, BRCA1.
Weiss said that for most women, the biggest factors are not hereditary but relate to how they lead their lives: weight, alcohol consumption, smoking, physical activity.
She anticipated that the interest level in genetic testing would soar after Jolie's intervention, but in many cases it would be inappropriate. "Whenever a celebrity steps forward that everybody knows like Angelina Jolie people are going to relate to her and think they have the same problem even though their situation is totally unconnected. For a time people are going to say 'I want the test that Angelina had'," Weiss said.
That could have financial implications. In the US it costs $3,000 or more to have the genetic test for BRCA1 or the related BRCA2. Where there is a strong family history of breast or ovarian cancer, health insurance firms are likely to pay for the procedure, but where none exists the individual will be expected to pay.
Dr Richard Francis, head of research at Breakthrough Breast Cancer, said that faults in the BRCA1 gene, which on average put women at a 65% risk of developing breast cancer, were rare and in most cases were linked to family history.
He cautioned that a mastectomy would not necessarily be the appropriate treatment for everyone with the gene. "For women like Angelina it's important that they are made fully aware of all the options that are available, including risk-reducing surgery and extra breast screening," he said.
"Though Angelina decided that a preventative mastectomy was the right choice for her, this may not be the case for another woman in a similar situation. We urge anyone who is worried about their risk of breast cancer to talk it through with their doctor.
The genetic short straw
'We were resigned to having it'
Angelina Jolie's decision to have a prospective double mastectomy will resonate with many other women who have discovered they have drawn a genetic short straw.