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Julie told us, “I believe you should know everything about your condition. The more that is known, the better the doctor can treat you.” Now, she faced a new set of choices. She recalled how her oncologist “laid out all the options.” They spoke for more than an hour. He told her the most proven way for a woman with a BRCA mutation to prevent future cancer is to have both breasts removed, a double mastectomy, and also have the ovaries taken out. “This reduces the risk of breast and ovarian cancer by more than 90 percent,” he said.

Julie paused, and her voice became heavy. “I’ll tell you,” she said, “I didn’t like the idea of mastectomy, particularly a double mastectomy.”

Julie asked him, “What if I don’t want that surgery?” He explained that another option was to take a medication like tamoxifen, which has been shown in some studies to decrease the risk of future breast cancer by as much as 50 percent. “But we really don’t know if that is true for women like you with BRCA mutations. And the medication does not prevent ovarian cancer.” He further explained that if Julie did not want surgery, she would be closely monitored for breast cancer with mammograms and MRI scans. But this kind of monitoring has not been proven to be as reliable as a mastectomy in saving lives. With respect to monitoring for ovarian cancer, he explained, “ultrasound and blood tests don’t reliably detect ovarian cancer at an early stage.”

Julie left the appointment without reaching a decision. “It was an awful lot to absorb,” she told us. “He didn’t press me to choose, and emphasized how personal the choice is for each woman.” Julie’s earlier preference to cede decision making to her doctor shifted. Here, she wanted to clearly assert her preferences. She thought about the statistics that had been given to her. Then she went on the Internet. After looking at several decision aids, she realized that she would not base her choice strictly on numbers. “I didn’t want to have any sense that I hadn’t done everything I could do. My breasts, even though they’re small, I knew I’d miss them. But in the end, I did everything: I chose the double mastectomy, had my ovaries removed, got chemotherapy and radiation therapy. And I came out feeling that if this cancer comes back, there was nothing that I skipped that could have prevented it.”

Mary Frances Luce has studied how patients manage the complexity of the choices they face. Some focus on only one aspect of the choice, disregarding the other outcomes. This reduces cognitive effort, lessens decisional conflict, and helps them cope. For example, some people may ignore all the possible side effects of surgery, “shielding themselves,” as Luce puts it, from thinking about the pain involved or the risk of being disfigured or debilitated; they focus only on the chance of survival. Others may focus on every potential side effect of surgery, and this detailed deliberation helps them cope. They feel more in control by having weighed each possible outcome, analyzing all aspects of the choice.

Julie told us, “I didn’t want to look back and say that I didn’t do all I could do.” She was again anticipating regret, regret that she might have been able to prevent the one outcome she feared more than anything else, not living to see her children grow up. This led her to reduce the cognitive effort in deciding to undergo surgery. “The ovaries required the least thought because I have two children, and someday I’ll be in menopause anyway. And I was told that having the ovaries out was actually a really simple operation.” She paused. “Well, it probably is. But when I had my ovaries out, I had already had four months of chemo, and three weeks before that I had had a double mastectomy, so at the time I had my ovaries out, my body was pretty shot.”

Despite this, Julie told us, “It’s sort of funny. After I recovered from the surgery, I went out with my husband and saw The Wizard of Oz on the big screen. And there was a very humorous scene when Dorothy is going down the yellow brick