'Drastic measures' and cancer decisions

During the 1990s, scientists discovered two gene mutations in the BRCA family of genes which significantly increase a woman's chances of developing breast and ovarian cancer. Consequently, as noted in a recent Los Angeles Times article by Anna Gorman, "Many oncologists recommend that women with the mutations consider having their ovaries, fallopian tubes and breasts removed prophylactically [as a precautionary measure] to reduce risk."

Yet controversy exists regarding this recommendation. Precautionary surgery of this kind has been termed "mutilating" and "extreme" and some question whether it is, in fact, justifiable, given that the organs appear to be healthy (no cancer is yet detectable), and there is a limited probability that the disease may one day appear. Some medical professionals instead encourage frequent monitoring and screening of patients with the BRCA mutation, so that if cancer appears, and as soon as it appears, aggressive surgery could then be pursued.

On one side, then, are those who stress that the integrity and order of the human body should be respected and not unduly violated (the "Principle of Integrity"), while on the other are those who stress that an individual organ or a part of the human body may be sacrificed if that sacrifice means continued survival for the whole person (the "Principle of Totality"). The solution to the dilemma of preventative surgery will lie somewhere in the middle, with emphasis being placed upon the weightier Principle of Totality. The decision to undergo preventative surgery will thus be ethically justifiable and reasonable in certain cases.

Nevertheless, even the scientist who discovered the BRCA mutation, Mary-Claire King, Ph.D., has acknowledged the incredible challenge raised by her discovery: "It is a very difficult thing to recommend prophylactic oophorectomy [removal of the ovaries] when it is healthy women you are talking about. It is a radical thing to consider in a feminist age." When it comes to a bilateral mastectomy [removal of both breasts], the difficulty is only compounded. As another researcher observed, "In western society at least, there is no organ as connected to femininity, sensuality, sexuality, adulthood and motherhood as the breast."

Anna Gorman, the LA Times staff writer who tested positive for the BRCA mutation and ended up opting to have her ovaries removed, described how she could not quite bring herself to have her breasts removed as well, even though her father, grandmother, and aunt had all died at an early age from cancer: "I was still getting used to the idea of losing my ovaries. I had always viewed a preventive mastectomy as a drastic measure. It seemed I risked losing nearly everything -- at least physically -- that defined me as a woman."

The real costs of this kind of surgery remind us of the importance of making a right and ethical decision for our circumstances. Although there is a heightened probability of disease, there is never any guarantee that a particular woman with the BRCA mutation will develop cancer. Some women will go on to develop cancer; others will not. So, while the surgical removal of ovaries and/or breasts will prevent the disease from developing in some women, in others it will make no difference, since they were never going to get the disease in the first place. In that situation, healthy organs (which secrete important hormones for the overall health of the person) would have been removed unnecessarily. As one researcher noted, "Many women who undergo prophylactic mastectomy will undoubtedly benefit from it, but nobody will ever know which ones..."

Given this strict inability to know who will develop cancer and who will not, other risk factors besides the BRCA mutation should be carefully considered before choosing to undergo preventative surgery. A strong family history of breast cancer at an early age, the absence of a full term pregnancy, an abortion or miscarriage of the first pregnancy, or a male relative who develops breast cancer are among the factors known to increase a woman's risk of developing breast cancer. In the end, after careful weighing and reflection, a woman should personally be convinced that she will develop cancer in the future in order to justify undergoing this radical kind of surgery.

Even in the face of several known risk factors, however, a woman may still wish to delay such preventative surgery until she has had the opportunity to have children, or she may freely choose against it altogether.

To sum up then, even though a woman with multiple risk factors can never categorically prove that she will develop cancer in the future, she may nevertheless arrive at prudential certitude that she will develop the disease after carefully assessing the various risk factors. Insofar as she achieves that prudential certitude within herself, she not only may, but ought to consider seriously the possibility of undergoing risk-reduction surgery.

Father Tadeusz Pacholczyk, Ph.D. earned his doctorate in neuroscience from Yale and did post-doctoral work at Harvard. He is a priest of the diocese of Fall River, MA, and serves as the Director of Education at The National Catholic Bioethics Center in Philadelphia. See www.ncbcenter.org.