Kallah teachers, BRCA genes and a tweak that could save lives | Top Vip News

Ten years ago, this author wrote an article advocating for an adjustment to our Kallah teacher curriculum regarding cancer screening. The adjustment could save lives. If we can get our Rabbonim and Gedolim to read and accept the change, it could make a big difference. The novelty is that the NIH in England offers testing and that it is now available in the form of a saliva test.

THE HALACHA

From time to time a medical problem arises that needs to be addressed urgently. Preventing and minimizing disease is a biblical imperative. The Gemara and the poskim understand that the verse in Devarim (4:15) “V’nishmartem me’od l’nafshoseichem” means that safeguards and measures must be taken to ensure our personal health and safety.

Thanks to advances in genetic testing, medical laboratories have been able to detect harmful mutations in genes called BRCA1 and BRCA2 since 1994. This test can and should be used to predict susceptibility to various forms of cancer. According to statistics, 80% of women with these defects will suffer from breast cancer.

THE PREVALENCE – 1 IN 40

Breast cancer affects Ashkenazi Jewish women at a staggering 1,200% more than the general population. One in forty Ashkenazi Jewish women has a malformed BRCA1 or BRCA2 gene. “There is no question,” says Dr. Herman, a respected obstetrician and gynecologist practicing on Long Island, “that all Ashkenazi women in our shuls and Jewish community centers should be tested for this. “It affects one in forty women.” A recent paper by Dr. Steven A. Narod of the University of Toronto and his co-authors was published in the Journal of Clinical Oncology that recommended that women who have harmful mutations in the BRCA gene should opt for removal of their ovaries at 35 years.

KALA MASTERS

In recent years, someone came up with the idea of ​​our kalah teachers advising kalahs to start taking folic acid even before they get married. The increase in folic acid in the bloodstream before marriage probably helped many fetuses develop normally. Based on conversations with expert doctors in the field of oncology, It is the opinion of this author that kallah teachers should make two additional recommendations. These recommendations will save lives.

THE TWO RECOMMENDATIONS

Everyone should strongly recommend that:

1. On the first birthday of her first child or before age 25 after marriage, every woman should be tested for BRCA mutations.
2. The second recommendation is that given the probability of 1 in 40 that the woman tests positive, at 35 years of age she opts for bilateral oophorectomy surgery.

This surgery would normally be prohibited for other women, but in this author’s opinion, based on data from the study results published in the Journal of Clinical Oncology, it is halachically recommended for women who test positive for these BRCA1 or BRCA2 mutations.

Why the age of 25? This is the first time that steps could be taken that could make a difference, and a good percentage of these young women would also be married at that time. At age 25, those who tested positive for BRCA could be taught more advanced self-examination techniques and receive safe medications that reduce the incidence of some cancers by 50%.

The study involved almost 6,000 women and showed that carriers of BRCA 1 and 2 mutations had an 80% lower risk of ovarian cancer if they underwent bilateral oophorectomy.

Oophorectomy was also associated with a 77% reduction in the risk of all-cause mortality, primarily due to the effect on the risk of ovarian and breast cancer. Dr. Narod said in a statement: “These data are so striking that we believe prophylactic oophorectomy before 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 forties, since their risk of ovarian cancer 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 frequently between ages 50 and 59 for BRCA1 carriers and between ages 60 and 69 for BRCA2 carriers.

GENERAL PROHIBITION

According to the Talmud (Shabbat 110b), the Torah prohibits “sirus,” actions that render a person unable to have children, based on the verse from Vayikra (22:24), “That which is bruised, crushed, torn, or cut.” . do not bring him before Hashem; nor shall you do this in your land.”

The Tosefta (Makkos 5:6) cites a debate about the status of women in this prohibition. Rabbi Yehudah’s opinion is that, with respect to women, one is “patur”: exempt.

The Rambam in Hilchos Issurei Biah (16:11) and the Shulchan Aruch (EH 5:11) seem to rule that such operations are generally prohibited but exempt. The Shulchan Aruch in the following halacha rules that, while it is prohibited to physically render a woman incapable of having children, a woman may ingest a liquid that renders her incapable of having children.

There is debate over whether sirus regarding women is a Torah or rabbinic prohibition. The Vilna Gaon (EH 5:25) understands that both the Rambam and the Shulchan Aruch hold that the prohibition comes from the Torah, only that the prohibition does not carry the punishment of whipping. The Aruch HaShulchan (EH 5:22) is of the same opinion. Rashba, Tosfos, Meiri and SMaG maintain that it is rabbinic.

Regardless of the status of the ban, all Aharonim rule that in case of great need this ban can be lifted. Certainly this would be true with respect to a question of pikuach nefesh.

In the past, some have questioned whether these recommendations should be implemented, due to two factors: (1) the anxiety that some women will experience upon learning that they are carriers of the gene and (2) the uncertain evidence that surgery would alleviate the situation.

However, this recent study puts this issue to rest. Both statistics have been validated: 80 percent of women with the genetic mutation are prone to cancer and 80 percent of women who have surgery at age 35 avoid cancer.

The question is pressing. Women who have a family history of these diseases should definitely be tested for BRCA1 and BRCA2 mutations. This issue affects all of Klal Yisroel and must be brought to the attention of our gedolei ha’poskim, who must investigate the issue and make determinations: The questions that need answers are: If and when should women be tested? When should surgery be performed? Is it a halachic obligation to perform the surgery?

Once again, this author believes that our Kallah teachers should teach about this. Specifically, on her first child’s first birthday or when she turns 25 after marriage, each woman should be tested for BRCA mutations.

The second recommendation is that, given the 1 in 40 chance that the woman tests positive, at 35 years of age she opts for bilateral oophorectomy surgery. This second recommendation should be reviewed when our ability to safely treat this cancer improves significantly.

Any Rav or Posaik who wishes to be included in a Kol Koreh or public letter to this effect, please email the author.

The author can be contacted at [email protected].