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Prophylactic Salpingectomy to Reduce the Risk of Cancer: Ethical Considerations

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Prophylactic Salpingectomy to Reduce the Risk of Cancer: Ethical Considerations FROM THE FIELD Prophylactic Salpingectomy to Reduce the Risk of Cancer: Ethical Considerations A Case May a salpingectomy be performed in A 28-year-old patient is 25 weeks conjunction with a C-section to reduce the pregnant with her second child. She is risk of cancer? scheduled for a C-section. She has two relatives who had ovarian cancer, one of Ministry Perspectives whom passed away from the disease. She knows that this family history increases Rev. Gerald D. Coleman, S.S., Ph.D. her risk of ovarian cancer. Vice President, Corporate Ethics Daughters of Charity Health System Ovarian cancer grows slowly. Pre-invasive Los Altos Hills, Calif. and early stage disease often go [email protected] undetected. Many patients have malignancies more than four years before Salpingectomy is a prophylactic, ovarian cancer is detected. By the time of preventative or cautionary surgery to diagnosis, the cancer is often advanced remove the fallopian tubes for women at and aggressive growth has already high risk of ovarian cancer. Between 1 in occurred. As a result, the five year survival 400 and 1 in 800 people in the U.S. rate is only about 45 percent. population carry one of the causative mutations, and salpingectomy has become At her last appointment, the patient tells the “standard of care” in these cases.1 her OB that she read that removal of the Ovarian cancer is a significant issue in fallopian tubes and the ovaries might help women’s health and the overall survival to prevent ovarian or breast cancer. The rate at five years is only about 45 percent. patient explains that she does not want For women with increased risk of ovarian removal of her ovaries, which will cancer, the lifetime risk ranges from 16 to prematurely cause menopause; however, 54 percent, and often involves an she asks whether she could undergo a risk- increased risk of breast cancer. Last year reducing salpingectomy (removal of the actress Angelina Jolie chose to have a fallopian tubes) in conjunction with her double mastectomy and reconstructive C-section. She is very concerned about her surgery after learning she had an 87 risk of cancer and has become increasingly percent risk of breast cancer because she anxious about her health after the birth of carries the BRCA1 gene.2 her child. Although salpingectomy will cause sterilization, the patient accepts that Ovarian cancer is not a single disease she will not be able to have another child. process arising on a single site or from a She is most concerned about reducing her single cell type. The most common risk of ovarian cancer. subtype has been identified as serous Copyright © 2015 CHA. Permission granted to CHA-member organizations and Saint Louis University to copy and distribute for educational purpose. 23 FROM THE FIELD (epithelial ovarian cancer), and the healthy organ removes the “field of fallopian tube is often the first place of growth" and dramatically diminishes the involvement. This subtype is most risk of life-threatening disease. commonly found in BRCA1/2 mutation carriers3 and up to 20 percent of these Regarding prophylactic mutilation, Pius cancers occur in women with germ line XII stated that "by virtue of the principle BRCA1/2 mutations.4 of totality and the right to use the services of the organism as a whole, each person A woman with BRCA mutations can can permit individual parts to be chose risk-reducing surgery to excise her destroyed or mutilated when the good of fallopian tubes and sometimes her ovaries the whole requires it. This may be done to (oophorectomy). When pathologically ensure life, as well as to avoid or, examined after surgery, about 10 percent naturally, repair serious and lasting of women undergoing salpingectomy were damage that cannot be otherwise be found to have an early cancer. The avoided or repaired."10 Healthy organs, majority of early cancers were found in the therefore, may be removed for the good of distal fallopian tubes and not the ovaries. the whole whenever their functioning Due to its location in the fallopian tubes, poses a physical risk. The decisive moral the cancer metastasizes to the ovaries and element is that the preservation of the surrounding pelvic structures. organ or its functioning poses a direct or indirect threat to the body.11 While salpingectomy is standard medical treatment, is this surgery in line with Consequently, salpingectomy is morally Catholic moral teaching that places permissible. Even though the surgery significant value on the preservation of the renders the generative faculty incapable of whole of the human person, stresses that a procreation, this is not its sole effect, or pathology must be present in order to the primary intention. Rather, the act of remove an organ,5 views mutilation of a removing the fallopian tubes (and healthy organ as intrinsically evil,6 and sometimes ovaries) is in itself sufficient for condemns direct sterilization?7 a notable clinical benefit conferred directly to the patient and this constitutes the Pope Pius XII delineates three conditions primary intention. when it is permissible to remove a healthy organ:8 the functioning organ is causing Categorizing salpingectomy a "drastic serious damage or constitutes a menace to measure," National Catholic Bioethics the whole organism; clear evidence Center's Director of Education Fr. Tad confirms that the damage will be Pacholczyk draws a helpful distinction remediated or measurably lessened by the between the importance that the integrity mutilation; and the negative effects of and order of the human body be respected mutilation will eliminate the danger to the and not unduly violated (the Principle of whole, ease the pain, or secure positive Integrity) and whether or not an effects.9 In other words, a removal of a individual organ or part of the human Copyright © 2015 CHA. Permission granted to CHA-member organizations and Saint Louis University to copy and distribute for educational purposes. 24 FROM THE FIELD body may be sacrificed for the continued 7 ERDs, op. cit., no. 53. 8 survival of the whole person (the Principle Barina, op. cit., 72, referencing “Removal of a Healthy Organ” in The Human Body, Boston: of Totality). Salpingectomy lies Daughters of St. Paul, 1960, 277-279. "somewhere in the middle, with emphasis 9 This same conclusion was reached by Thomas J. being placed upon the weightier Principle O’Donnell, “Definitive Pelvic Surgery: A Moral of Totality."12 Evaluation,” Theological Studies 22:4 (1961), 652- 653. 10 Pope Pius XII, AAS 44 (1952), 782. Pacholczyk rightly concludes that a 11 See Gerald Kelly, S.J., "Pope Pius XII and the woman can surely make a prudential Principle of Totality, " Theological Studies 16: 2 judgment that she carries a serious risk of (1955), 373-396. breast cancer due to BRCA1/2 mutations, 12 Fr. Tad Pacholczyk, "'Drastic Measures' and as well as considering other factors such as Cancer Decisions,'" (November 7, 2014), http://ncbcenter.org/page.aspx?pid=1101. a strong family history of breast cancer, 13 See Victoria Colliver, "UCSF Study To Look at the absence of a full-term pregnancy, Effects of Premature Change As A Result of abortion or miscarriage in the first Preventive Breast or Ovary Removal," Health. pregnancy, or a male relative who SFChronicle.com and SFGate.com, November 19, develops breast cancer.13 2014. Salpingectomy is prudential management medical treatment and morally permissible Emily Trancik, Ph.D. (c) surgery. Ethics Fellow Ascension Health 1 Consult: Rachelle Barina, “Risk-Reducing St. Louis Salpingectomy and Ovarian Cancer,” The National [email protected] Catholic Bioethics Quarterly 14:1 (2014), 67-79 and John F. Tuohey, “Surgical Prophylactics for Cherie Sammis Ovarian Cancer (SPOC): An Ethical Inquiry,” Vice President, Mission Integration Linacre Quarterly 65:3 (1998), 77-96. 2 Jolie's mother and aunt both died of breast St. Mary's of Michigan Medical Center cancer. She chose this surgery as her risk of breast Saginaw, Mich. cancer was higher than her risk for ovarian cancer. [email protected] 3 http://www.cancer.gov/cancertopics/factsheet/Risk Becket Gremmels, Ph.D. (c) /BRCA 4 Gynecologic Oncology Statement Regarding Executive Director, Ethics Salpingectomy and Ovarian Cancer Prevention, Saint Thomas Midtown Hospital November 2013, https://www.sgo.org/linical- Nashville, Tenn. practice/guidelines/sgo-climnical-practice- [email protected] statement-salpingectomy-for-ovarian-cancer- prevention/. 5 NCCB, Ethical and Religious Directives for The fear and emotional angst many Catholic Health Care Services (ERDs), 2009, no. women experience from a heightened risk 53. of developing ovarian cancer can be 6 John Paul II, Veritatis Splendor (1993), no. 80. overwhelming, especially if they have lost See also Thomas Aquinas, Summa Theologiae I-II, family members to this dreaded disease. q. 65, a. 1. Copyright © 2015 CHA. Permission granted to CHA-member organizations and Saint Louis University to copy and distribute for educational purposes. 25 FROM THE FIELD Since Catholic health systems carry a physician. Rather, its purpose is to reduce moral obligation to care for the whole the risk of cancer in the face of danger. person, attending to such fears and anxiety Finally, the sterilizing effect is not the is essential when ministering to these cause or specific means used to reduce the patients. The difficult decisions these risk of ovarian cancer. women and their families face requires our support and the best medical care we can Although prophylactic salpingectomy offer. At the same time, Catholic meets the first three conditions for double ministries must respond in a way that effect, it is more difficult to determine ensures respect for human dignity and the whether the good effect outweighs the whole human person, including the gift of bad.
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