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  • Writer's pictureSociety of Bioethics and Medicine

Navigating the Ethical Waters: Prophylactic Surgery and the BRCA Gene Debate

Written by Amanda Pisciotta

Edited by Sanjana Ahmed


In a world where autonomy over one's body is fiercely debated, women grapple with a daunting decision – prophylactic surgery. This ethical battleground unfolds in the realm of BRCA genes, genetic markers that can catapult individuals into a high-risk category for breast and ovarian cancers. The stakes are high as women confront a lifelong dilemma: surrender their bodies to invasive procedures with no guarantee of becoming patients, or brave the somber statistics sans intervention. This debate is not just about tissues and organs; it is about women’s fundamental right to make informed choices about their bodies in the face of looming probabilities.


Prophylactic surgery is a preventive measure that involves the removal of tissues that harbor the potential for future cancer development[1]. Women who test positive for BRCA genes may decide to preemptively remove ovaries or undergo preventive mastectomies to stave off the looming threats of cancer[1]. The debate intensifies as the ethical question emerges – should women be empowered to make these decisions and take charge of their health, or should society continue to dictate the trajectory of their bodies? As we delve into the ethical intricacies of this life-altering decision, it becomes evident that the discourse extends beyond medicine to touch the core of autonomy, gender, and the right to shape one's medical journey and future.


Breast cancer's complexity lies in cellular anomalies within the breast's fundamental components—lobules, ducts, and connective tissue[2]. Uncontrolled cell growth in these areas can lead to breast cancer, often originating in ducts or lobules and potentially metastasizing through blood and lymph vessels[2]. In the U.S., the average risk for a woman to develop breast cancer is 13%, equating to a 1 in 8 chance[3]. Breast cancer constitutes 12% of all new cancer cases, with an estimated 297,790 new diagnoses in 2023[4]. Shockingly, a woman in the U.S. receives a breast cancer diagnosis every two minutes, emphasizing the need for a comprehensive understanding of its prevalence and impact[4].


Ovarian cancer, emerging in the ovaries, involves rapidly multiplying cells that can invade and destroy healthy tissues[5]. Despite its rarity, ovarian cancer ranks fifth in cancer-related deaths among women, with a lifetime risk of 1 in 78 and a lifetime chance of succumbing to the disease at 1 in 108[6]. The grim five-year survival rate of 49.7% and early-stage detection in only 17% of cases underscore the urgency for heightened awareness and research into more effective diagnostic and treatment strategies[7]. As women face these somber statistics, the ethical debate on prophylactic surgery gains relevance, emphasizing the need to empower individuals to make informed decisions about their bodies in the face of these formidable adversaries.


BRCA1 and BRCA2 are genes that produce proteins crucial for DNA repair and are key components in cancer[8]. Termed tumor suppressor genes, any harmful mutations in BRCA1 and BRCA2 significantly elevate the risk of several cancers, particularly breast and ovarian cancer[8]. Inheritance of harmful variants in these genes is associated with an earlier onset of cancer, highlighting the urgency of understanding and addressing this genetic predisposition.


When comparing the risks associated with BRCA gene mutations to the general population, the differences are stark. In the general population, about 13% of women will develop breast cancer during their lifetime. In contrast, women inheriting a harmful BRCA1 variant face a 55%–72% likelihood, while those with a harmful BRCA2 variant have a 45%–69% chance of developing breast cancer by the age of 70–80[9]. The risk of contralateral breast cancer increases significantly for individuals with BRCA gene mutations, reaching 20%–30% at 10 years post-diagnosis and escalating to 40%–50% at 20 years[9]. For ovarian cancer, which afflicts approximately 1.2% of women in the general population, the stakes are considerably higher for those with BRCA gene mutations[9]. Women with a harmful BRCA1 variant face a 39%–44% likelihood, while those with a harmful BRCA2 variant have an 11%–17% chance of developing ovarian cancer by the age of 70–80[9].


In the relentless battle against ovarian and breast cancers, surgery is a critical weapon, often in conjunction with chemotherapy and radiation therapy. For ovarian cancer, the primary treatment approach involves the surgical removal of as much cancerous tissue as possible[10]. The surgical process, often conducted through an abdominal incision called laparotomy, aims to remove cancer from various pelvic and abdominal organs, including the uterus, fallopian tubes, bladder, and bowel[10]. If the cancer is confined to the ovary, the surgeon may explore the abdomen for potential cancer cells through fluid examination[10]. While preserving fertility is a consideration, the extent of surgery may involve unilateral or bilateral oophorectomy, salpingectomy, hysterectomy, and, if necessary, the removal of lymph nodes and sections of the bowel[10]. 


Shifting to breast cancer, surgery takes center stage as the primary treatment. Mastectomy and lumpectomy are the two primary methods employed to remove tumors[11]. Lumpectomy, or partial mastectomy, removes individual tumors with a margin of healthy tissue and is often suitable for early-stage breast cancer[11]. Mastectomies involve the removal of one or both breasts and may extend to additional tissues if affected[11]. Sentinel node biopsy and lymphadenectomy assess lymph nodes for potential cancer spread, while breast reconstruction procedures aim to restore breast shape post-cancer removal[11]. 


As we witness a gradual decline in ovarian and breast cancer deaths due to early detection and successful treatments, like these surgical procedures, the ethical question remains: Is it ethical to empower invasive surgeries for individuals with BRCA mutations who have a statistical likelihood of developing cancer but are undiagnosed[12,13]?


The debate surrounding prophylactic surgery, particularly for individuals with the BRCA gene, unfolds as a complex ethical dilemma with multifaceted considerations. While doctors often recommend surgery for women with a BRCA1 or BRCA2 mutation due to their elevated risk of breast and ovarian cancer, the decision is far from straightforward[14]. Prophylactic oophorectomy, the removal of ovaries and fallopian tubes, significantly reduces the risk of ovarian cancer but comes at the cost of inducing menopause, with associated symptoms such as hot flashes and emotional challenges[14]. Similarly, a prophylactic mastectomy, though capable of lowering breast cancer risk by 90% or more, poses physical and psychological consequences, including bleeding, infection, loss of sensation, and alterations in body image[14].


The ethical discourse intensifies as the statistics reveal that approximately 30% of women, following genetic testing, consider the potential risk and opt for prophylactic surgery due to concerns about genetic breast cancer risk[15]. Notably, 86.4% of women with an abnormal BRCA1 or BRCA2 gene choose a double mastectomy[15]. However, the debate takes a critical turn as arguments against prophylactic surgery emerge, emphasizing the potential harm and risks associated with these preventive measures. Prophylactic mastectomy, while significantly reducing the risk for those with multiple breast cancer risk factors, may not benefit individuals with an average risk, exposing them to potential complications such as bleeding, infection, and dissatisfaction with body appearance without the assurance that they will remain cancer-free[16].


The ethical dilemma hinges on the principle of individual autonomy, emphasizing the right of each person to make decisions about their own body and health. The debate oscillates between the potential benefits of preventing cancer and the significant physical and emotional toll of prophylactic surgeries. The question of whether prophylactic surgery is perceived as a preventive measure or a form of mutilation further adds to the complexity of the discourse[17]. As women grapple with these decisions, it becomes imperative to navigate the ethical terrain, ensuring that autonomy is preserved, risks are transparently communicated, and the potential disparities in access to these interventions based on financial stability and insurance coverage are addressed.


The bioethical discussion on prophylactic surgeries for individuals with the BRCA gene is complicated by insurance coverage and financial implications. While autonomy in health decisions is essential, financial stability and insurance coverage often compromise this choice. Genetic testing for BRCA mutations, usually covered by insurance, becomes intricate for prophylactic surgeries due to state variations and limited federal laws[18]. New York State mandates coverage, but federal laws lack consistency, and Medicare's policy adds complexity[19,20].

Financial burdens are significant, with deductibles and copays applying even with insurance[21]. Approximately 11% of women aged 19-64 in the U.S. were uninsured in 2021, disproportionately affecting low-income, women of color, and non-citizen women[22]. The ethical dilemma deepens as financial considerations play a crucial role, impacting decision-making. Despite desires to discuss costs, few women engage in these conversations with medical teams. The financial implications extend beyond the surgery, affecting the entire trajectory of cancer risk reduction.

In essence, the bioethical discourse on prophylactic surgeries must consider economic realities and systemic healthcare disparities. As we advocate for individual autonomy, addressing barriers imposed by financial instability and insurance coverage is crucial, preventing disproportionate burdens on vulnerable populations. The investigation into socio-demographic factors influencing access to genetic testing for the BRCA gene raises critical questions about statistics' accuracy and healthcare resource distribution.


While everyone possesses the BRCA1 and BRCA2 genes, the prevalence of mutations varies across different ethnic groups. For instance, one in 40 Ashkenazi Jewish women has a BRCA gene mutation, leading to an increased risk of breast cancer at a young age[23]. If a parent carries the mutation, there is a 50% chance of the same mutation being inherited[23].


However, a 2009 study in the journal Cancer delved into the relationship between ethnicity and BRCA mutations in the United States, revealing that self-reported women with African or Latin American ancestry were more likely to have BRCA mutations, especially BRCA1 mutations[24]. However, the specific mutations prevalent in these groups remain an ongoing area of study.

Moreover, ethnicity plays a role in access to genetic counseling and testing. A recent study in Cancer uncovered disparities, indicating that doctors might be less likely to discuss genetic counseling and testing with black women and Spanish-speaking Hispanic women at risk for BRCA mutations[24]. This raises concerns about equitable healthcare delivery and the need for interventions to ensure that all individuals with risk factors for BRCA mutations have equal access to genetic services.


In essence, the socio-demographic factors shaping the landscape of BRCA gene mutations illuminate a complex interplay between genetic predisposition, ancestry, and access to healthcare resources. In addition to the ethical dimensions of prophylactic surgeries and risk reduction, it is crucial to address these disparities, ensuring that healthcare decisions are informed by accurate and representative data across diverse populations.


While there are notable non-profit initiatives aimed at supporting individuals at risk of BRCA gene mutations, it's essential to acknowledge the limitations in covering the diverse spectrum of women who may benefit from these resources. Organizations such as FORCE (Facing Our Risk of Cancer Empowered) offer valuable guidance and information but do not provide direct financial assistance[25]. Instead, they steer individuals towards resources like the Alliance in Reconstructive Surgery (AiRS) Foundation, which grants assistance for breast reconstructive surgery, specifically targeting women in need[25]. Additionally, federally qualified health centers and Hill-Burton facilities serve as valuable resources for those requiring financial assistance with health and preventive care, catering to individuals with limited income[25].


Despite these initiatives, challenges persist in providing comprehensive coverage for prophylactic surgeries. The Medicare Rights Center, a national non-profit organization, works towards ensuring access to affordable healthcare for Medicare recipients, addressing some of the financial hurdles[25]. The Patient Advocate Foundation plays a crucial role by providing case managers who assist in identifying financial assistance programs and resources for individuals facing challenges[25]. However, the extent of coverage and accessibility remains a critical consideration, urging a closer examination of the effectiveness of these initiatives in reaching a diverse range of women.


As the landscape of genetic testing and prophylactic surgeries evolves, there is a collective responsibility to enhance the reach and impact of non-profit initiatives, fostering inclusivity and equitable access to crucial healthcare resources. 


In conclusion, the ethical considerations surrounding prophylactic surgery and the BRCA gene highlight the delicate balance between risk reduction and individual autonomy. While these surgeries significantly lower the risk of breast and ovarian cancers associated with BRCA mutations, the decision involves multifaceted factors. Despite the importance of allowing individuals control over their bodies and recognizing the personal nature of healthcare, financial implications, and accessibility disparities hinder autonomy, raising concerns about equitable intervention distribution. The conversation extends beyond BRCA genes, shedding light on broader societal issues regarding women's autonomy. To address these challenges, comprehensive healthcare reforms, financial assistance programs, and inclusive initiatives are crucial for ensuring everyone, regardless of socio-economic status, can make informed health choices. The right to bodily autonomy is a fundamental human right that warrants collective attention and action.


References:

  1. “Surgery as a Preventive Measure.” Surgery as a Preventive Measure | SEER Training, training.seer.cancer.gov/treatment/surgery/types/preventive.html. Accessed 17 Nov. 2023. 

  2. “What Is Breast Cancer?” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 25 July 2023, www.cdc.gov/cancer/breast/basic_info/what-is-breast-cancer.htm

  3. “Breast Cancer Statistics: How Common Is Breast Cancer?” Breast Cancer Statistics | How Common Is Breast Cancer? | American Cancer Society, www.cancer.org/cancer/types/breast-cancer/about/how-common-is-breast-cancer.html#:~:text=Overall%2C%20the%20average%20risk%20of,will%20never%20have%20the%20disease. Accessed 17 Nov. 2023. 

  4. “Breast Cancer Statistics and Resources.” Breast Cancer Research Foundation, 15 Apr. 2023, www.bcrf.org/breast-cancer-statistics-and-resources/

  5. “Ovarian Cancer.” Mayo Clinic, Mayo Foundation for Medical Education and Research, 9 May 2023, www.mayoclinic.org/diseases-conditions/ovarian-cancer/symptoms-causes/syc-20375941

  6. “Ovarian Cancer Statistics: How Common Is Ovarian Cancer.” Ovarian Cancer Statistics | How Common Is Ovarian Cancer | American Cancer Society, www.cancer.org/cancer/types/ovarian-cancer/about/key-statistics.html#:~:text=Ovarian%20cancer%20ranks%20fifth%20in,is%20about%201%20in%20108. Accessed 17 Nov. 2023. 

  7. “Hereditary Breast Cancer and BRCA Genes.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 21 Mar. 2023, www.cdc.gov/cancer/breast/young_women/bringyourbrave/hereditary_breast_cancer/index.htm.  

  8. “Taking Charge: How Is Ovarian Cancer Treated?” Ucsfhealth.Org, UCSF Health, 8 May 2023, www.ucsfhealth.org/education/taking-charge-how-is-ovarian-cancer-treated

  9. Professional, Cleveland Clinic medical. “Breast Cancer Surgery: All You Need to Know.” Cleveland Clinic, my.clevelandclinic.org/health/treatments/8338-breast-cancer-surgery. Accessed 17 Nov. 2023. 

  10. “Ovarian Cancer Statistics: How Common Is Ovarian Cancer.” Ovarian Cancer Statistics | How Common Is Ovarian Cancer | American Cancer Society, www.cancer.org/cancer/types/ovarian-cancer/about/key-statistics.html#:~:text=Fewer%20women%20are%20dying%20of,being%20diagnosed%20and%20better%20treatment. Accessed 17 Nov. 2023. 

  11. “Breast Cancer Death Rates Are Highest for Black Women-Again: Breast Cancer Facts & Figures, 2022-2024.” Breast Cancer Facts & Figures, 2022-2024 | American Cancer Society, 3 Oct. 2022, www.cancer.org/research/acs-research-news/breast-cancer-death-rates-are-highest-for-black-women-again.html#:~:text=Still%2C%20the%2043%25%20overall%20decline,well%20as%20improvements%20in%20treatment

  12. “Rates of BRCA Testing Increasing in Younger Diagnosed Women.” Breastcancer.Org - Breast Cancer Information and Support, Breastcancer.org, 31 July 2022, www.breastcancer.org/research-news/brca-testing-increasing-in-younger-dx-women#

  13. “Surgery to Reduce the Risk of Breast Cancer Fact Sheet.” National Cancer Institute, www.cancer.gov/types/breast/risk-reducing-surgery-fact-sheet. Accessed 17 Nov. 2023. 

  14. “Does Insurance Cover a Preventative Mastectomy: Nyship and Other Options.” Harris Plastic Surgery, 16 Aug. 2023, harrisplasticsurgery.com/2023/08/11/does-insurance-cover-preventative-mastectomy-hps/#:~:text=For%20health%20insurance%20policies%20issued,high%20risk%20for%20breast%20cancer

  15. “Medicare & Medicaid.” Coverage of Prophylactic Surgery - Medicare & Medicaid, www.facingourrisk.org/support/insurance-paying-for-care/screening-and-prevention/risk-reducing-surgery/medicare-and-medicaid. Accessed 17 Nov. 2023. 

  16. “Overview.” Prophylactic Surgery Coverage - Overview, www.facingourrisk.org/support/insurance-paying-for-care/screening-and-prevention/risk-reducing-surgery/overview. Accessed 17 Nov. 2023. 

  17. “Jewish Women and BRCA Gene Mutations.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 21 Mar. 2023, www.cdc.gov/cancer/breast/young_women/bringyourbrave/hereditary_breast_cancer/jewish_women_brca.htm#:~:text=One%20in%2040%20Ashkenazi%20Jewish,cancer%20at%20a%20young%20age

  18. Mayer, Melissa. “BRCA Gene Mutation Risks: Ethnicity, Genetics, and More.” Healthline, Healthline Media, 27 July 2020, www.healthline.com/health/ovarian-cancer/ethnicity-and-your-brca-ovarian-cancer-risk#ethnicity

  19. “Financial Assistance.” Financial Assistance for Prophylactic Surgery, www.facingourrisk.org/support/insurance-paying-for-care/screening-and-prevention/risk-reducing-surgery/financial-assistance. Accessed 17 Nov. 2023.

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