Ten years ago, this author wrote an article that advocated a tweak to our kallah teacher curriculum having to do with cancer screening. The tweak could save lives. If we got our rabbonim and gedolim to read and agree to the tweak, it could make a huge difference. What’s new is that the NHS in England is offering tests, and that it is now available in a saliva test.
The Halacha
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 meod 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.
Because of advances in genetic testing, medical labs have been able since 1994 to detect harmful mutations in the genes called BRCA1 and BRCA2. This testing can and should be used to predict a propensity to several forms of cancers. According to statistics, 80% of women with these defects will get women’s cancer.
The Prevalence: One in 40
Breast cancer affects Jewish Ashkenazi women by an astounding 1,200% more than it affects the general populace. One in forty Ashkenazi Jewish women has a malformed BRCA1 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 1 in 40 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 recommended that women who have the harmful BRCA gene mutations should opt for removal of the ovaries at age 35.
Kallah Teachers
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 bloodstream before marriage probably helped many fetuses develop normally. 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. These recommendations will save lives.
The Two 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 mutations.
- The second recommendation is that on the 1 in 40 chance that the woman tests positive, at the age of 35 she should opt for bilateral oophorectomy surgery.
This surgery would normally be prohibited for other women but, in this author’s view 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 these BRCA1 or BRCA2 mutations.
Why the age of 25? 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 twenty-five, those who tested BRCA positive could then be taught more advanced self-examination techniques and be put on safe medications that reduce the incidence of some cancers by 50%.
The study involved almost 6,000 women and showed that carriers of the BRCA 1 and 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, “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 mutation carriers and 10 in BRCA2 mutation carriers. Cancer diagnosis occurred most often during ages 50 to 59 for the BRCA1 carriers and 60 to 69 for the BRCA2 carriers.
General Prohibition
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 (Even HaEzer 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 (Even HaEzer 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 (Even HaEzer 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 Acharonim 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) uncertain evidence that the surgery would alleviate the situation.
However, this recent study puts this issue to bed. Both statistics have been validated: 80% of women with the gene mutation are prone to the cancer and 80% 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 the BRCA1 and BRCA2 mutations. This issue affects all of klal Yisroel and should be brought to our gedolei haposkim who should investigate the issue and make determinations: The questions that need answers are: If and when should women be tested? When should the surgery be done? Is it a halachic obligation to do the surgery?
Once again, this author believes that our kallah teachers should teach about it. Specifically, that upon the first birthday of their first child or by age 25 after marriage, each woman should be tested for BRCA mutations.
The second recommendation is that—on the 1 in 40 chance that the woman tests positive—at the age of 35, she should opt for bilateral oophorectomy surgery. This second recommendation should be revisited when and if our ability to safely treat this cancer improves significantly.
Any rav or posek that wishes to be included in a kol koreh or public letter to this effect—please email the author.
The author can be reached at [email protected].
