In a study reported in the Annals of Surgical Oncology, Henry Kuerer, M.D., and colleagues asked 481 medical directors of health insurance plans if their organizations would pay for prophylactic mastectomy or removal of the ovaries in women at high risk of breast or ovarian cancer. Of the 150 medical directors who answered, 30 percent would pay for prophylactic mastectomy; 30 percent would not pay; and 40 percent had no policy on the issue, which usually means the insurer makes the decision of whether to pay when the situation arises. As far as removing ovaries for preventive reasons, only 20 percent would pay; 25 percent would not pay; and more than 50 percent of health plans would decide on a case-by-case basis.

A small percentage of women have a high risk of developing breast or ovarian cancer for genetic reasons. Some have strong family histories of these cancers, along with gene mutations called BRCA1 and BRCA2. Others have the family history but no mutation has been detected so far. Generally, a strong family history means that several close relatives -- mothers, aunts and sisters -- have had the cancer, often at an early age, usually younger than 50.

Although women can take a drug called tamoxifen that will lower their risk of breast cancer by half, many feel they don't want to take a chance, especially if they have the BRCA1 or BRCA 2 mutation. A study published in the journal The Lancet by. E.J. Meijers-Heijboer, Ph.D. or M.D., and colleagues from Erasmus University in Rotterdam reported on a population of 68 Dutch women who were found to have this mutation. Half of the women chose to have prophylactic mastectomy and 60 percent chose to have their ovaries removed even though they had no evidence of cancer in either of these organs.

In another report, published in the Journal of Clinical Oncology by Ellen Matloff and her colleagues from Yale University, a group of American female genetic counselors were asked what they would do if they had the BRCA mutation. One-fourth responded that they would opt for mastectomy and 68 percent said they would have their ovaries removed. One startling finding was that most would not bill their insurance companies for the BRCA test because they were afraid they would lose coverage.

Recent studies have estimated the average benefit of preventive surgery at between three and six added years of life for a 30-year-old woman who chooses prophylactic mastectomy and removal of the ovaries. This is considered a huge gain in life expectancy for any preventive measure.

In an earlier study of prophylactic mastectomies by Mayo Clinic researchers, the breast cancer rate dropped by more than 90 percent after prophylactic mastectomy. The reason that some breast cancers still occurred is that it is difficult to remove all of the breast tissue and, in some of the surgeries, some breast tissue was deliberately left behind to preserve the nipple. These days, the surgery is more thorough.

In an editorial accompanying the article on insurance in the Annals of Surgical Oncology, Monica Morrow, M.D., a leading breast cancer surgeon at Northwestern University writes that doctors are not able yet to determine with precision if a woman is an appropriate candidate for a prophylactic mastectomy. "Our ability to assess risk is in its infancy," she writes.

Yet, Dr. Morrow adds that that it would be very difficult to set a definite policy "because individual women tend to view elevated levels of risk in different ways." She suggests all women with a high risk of breast or ovarian cancer undergo extensive counseling.

In addition, Dr. Kuerer and his colleagues say all of these women should be covered by their insurance for these surgeries. "Because prophylactic mastectomy and oophorectomy (ovariectomy) remain options among the risk-reducing techniques for women, our healthcare system should provide all appropriate candidates with equal access and coverage for these procedures," the researchers write.