By Rabbi Yair Hoffman
Every so often a medical issue comes to the fore that urgently needs to be addressed. The prevention and minimization of disease is a biblical imperative. The verse in Devarim (4:15) “Venishmartem me’od lenafshoseichem” is understood by the Gemara and the poskim to mean that safeguards and measures must be taken to ensure our personal health and safety.
Since the year 1994, defects in something called the “BRCA-1 and BRCA-2 genes” can be detected through advances in genetic testing. This testing can and should be used to predict a propensity to various forms of cancers. According to statistics, 80% of women with these defects will get women’s cancer.
One in Forty
Breast cancer affects Jewish Ashkenazi women by an astounding 1200% more than it affects the general populace. One in forty Ashkenazi Jewish women has a malformed BRCA or BRCA2 gene. “There is no question,” remarks Dr. Herman, a well-respected ob-gyn with a practice on Long Island, “that every Ashkenazic female in our shuls and Jewish community centers should be tested for this. It affects one in forty women.” A recent article by Steven A. Narod, MD, of the University of Toronto, and co-authors was published in the Journal of Clinical Oncology that went a step further than just recommending testing. It recommended that women who have the BRCA1 gene should opt for removal of the ovaries at age 35, and for those that have BRCA2 should opt for removal by age 40.
In recent years, someone came up with the idea to have our Kallah teachers advise Kallahs to start taking folic acid even before they get married. The rise in folic acid in the blood stream before marriage probably helped many fetuses develop normally, preventing many diseases. Based on discussions with expert doctors in the field of oncology, it is this author’s view that the Kallah teachers should make two additional recommendations.
They should all strongly recommend that upon the first birthday of their first child or by age 25 after marriage, each woman should be tested for BRCA. The first birthday idea is to address the fact that if the Kallah gets tested near marriage or near a birth, she could develop unhealthy anxieties. The second recommendation is that on the 1 in 40 chance that the woman tests positive, at the age of 35 (or 40) she should opt for bilateral oophorectomy surgery. This is a surgery that would normally be prohibited for other women but, in the view of many Poskim, based upon the data in the study results published in the Journal of Clinical Oncology, is halachically recommended for women who do test positive for BRCA1 or BRCA2.
Why the age of 25 or at the first birthday of a baby? This is the first time that action could be taken that might make a difference, and a good percentage of these young ladies would be married by that time too. At 25, those who tested BRCA positive could then be taught more advanced self-examination techniques and be put on very safe medications that reduce the incidence of some cancers by 50%.
The study involved almost 6000 women and showed that carriers of the BRCA 1-2 mutations had an 80% lower risk of ovarian cancer if they underwent bilateral oophorectomy.
Oophorectomy also was associated with a 77% reduction in the hazard for all-cause mortality, owing primarily to the effect on ovarian and breast cancer risk. Dr. Narod said in a statement. “These data are so striking that we believe prophylactic oophorectomy by age 35 should become a universal standard for women with BRCA1 mutations.” He continued that, “Women with BRCA2 mutations, on the other hand, can safely delay surgery until their 40s, since their ovarian cancer risk is not as strong.”
Among women with intact ovaries, 98 of 108 ovarian cancers occurred in BRCA1 carriers and 10 BRCA2 mutation carriers. Cancer diagnosis occurred most often during ages 50 to 59 for BRCA1 carriers and 60 to 69 for the BRCA2 carriers.
According to the Talmud (Shabbos 110b), the Torah forbids “sirus” – actions that render a person incapable of having children, based on the verse in Vayikra (22:24), “That which is bruised crushed torn or cut do not bring before Hashem, Neither shall you do this in your land.”
The Tosefta (Makkos 5:6) cites a debate as to the status of females in this prohibition. It is the view of Rabbi Yehudah that regarding females, one is “patur” – exempt.
The Rambam in Hilchos Issurei Biah (16:11) and the Shulchan Aruch (EH 5:11) both seem to rule that such operations are generally forbidden but exempt. The Shulchan Aruch in the next halacha rules that while it is forbidden to physically render a woman incapable of having children, a woman may ingest a liquid which will cause her to be incapable of having children.
There is a debate as to whether sirus in regard to women is a Torah prohibition or a Rabbinic one. The Vilna Gaon (EH 5:25) understands both the Rambam and the Shulchan Aruch as holding that the prohibition is indeed from the Torah, it is just that the prohibition does not carry with it the punishment of lashes. The Aruch HaShulchan (EH 5:22) is of the same view. The Rashba, Tosfos, Meiri and SMaG all hold that it is Rabbinic.
Regardless as to the status of the prohibition, the Achronim all rule that for great need this prohibition may be set aside. Certainly, this would be true regarding an issue of pikuach nefesh.
In the past, some questioned whether these recommendations should be implemented on account of two factors: 1] the anxiety that some of the women will experience in knowing that they carry the gene and 2] whether there was evidence that the surgery would alleviate the situation.
However, this recent study puts this issue to bed. Both statistics have been validated. 80 percent of women with the gene mutation are prone to the cancer and 80 percent of the women who have the surgery at age 35 avoid the cancer.
The issue is a pressing one. Women who have a family history of these illnesses should definitely get screened for BRCA1 and BRCA2. This author is currently in the process of presenting the questions regarding these medical issues to Gedolei HaPoskim: When should they be tested? When should the surgery be done? Is it a halachic obligation to do the surgery? So far, the Poskim I have consulted are in agreement with the recommendations set forth in this article.