Ethical Dilemma: Cancer and Pregnancy - Essay Example

Ethical Dilemma: Cancer and pregnancy. Current paper presents discussion of ethical dilemma in the area of medicine. The basic of research is placed on the ethical issues in the case with bowel cancer and pregnant woman who has to take a decision of what treatment to take in her particular situation. I will first review the theory related to medical ethics, then I will describe ethical dilemma and provide its solution in reference to possible alternatives and related issues. Ultimately, I will draw conclusions and come up with summaries and recommendations. Among many prominent theories in the field of ethics and behaviours, the theory of utilitarianism plays an important role. In a series of influential essays, Renee Fox (1989, 1990, Fox & Swazey 1984), the follower of the utilitarianism theory, has argued that the "ethos" of medical ethics has been dominated by an analytic individualism, organized around the value of "autonomy," that assigns prominence to "the notion of contract" while relegating "more socially-oriented values . . . to a secondary status" (1989, pp. 229-30). The bases of the teory enunciated the principle of the "voluntary consent" of human subjects as essential to the ethical conduct of research. The creed which accepts as the foundation of morals, Utility, or the Greatest Happiness Principle, holds that actions are right in proportion as they tend to promote happiness, wrong as they tend to produce the reverse of happiness. By happiness is intended pleasure, and the absence of pain; by unhappiness, pain, and the privation of pleasure. To give a clear view of the moral standard set up by the theory, much more requires to be said; in particular, what things it includes in the ideas of pain and pleasure; and to what extent this is left an open question. But these supplementary explanations do not affect the theory of life on which this theory of morality is grounded- namely, that pleasure, and freedom from pain, are the only things desirable as ends; and that all desirable things (which are as numerous in the utilitarian as in any other scheme) are desirable either for the pleasure inherent in themselves, or as means to the promotion of pleasure and the prevention of pain. Choosing among treatment options for any kind of cancer is challenging. When physicians disagree about the efficacy of various treatments, the task is especially daunting. In support groups, people with various cancer diagnoses often talk about feeling bewildered when they discussed their treatment options with surgeons and oncologists. Trying to comprehend all the information concerning the benefits and risks of different treatments shortly after hearing their cancer diagnosis was staggering. Mry N, thirty-fiv-old music tchr, ws dignosd with bowl cncr ftr sh found out tht sh hs bn prgnnt for six months. Sh discovrd suspicious lump on hr bowl just 24 hours ftr finding out sh ws prgnnt. Hr husbnd John nd hrslf r vry dlightd to hv th bby, but it sms to b dngrous for th livs of both. Doctors bliv tht sh risks to di or to giv birth to child with diffrnt kinds of hlth complictions. It hs to b dcidd thn wht is th bst wy to dl with dilmm; to find out wht is th bst trtmnt in prticulr sitution nd ftr crful considrtion of ptint's physicl condition to promptly undrtk ncssry intrfrnc. Mry's sitution is quit common s thr r css obsrvd nd womn trtd with this kind of dilmm. Now so mny, howvr, nd it provs th nd of individul pproch to th ptint. s it ws dignosd mor bowl cncr, t n rlir stg, nd r mor likly to us multignt chmothrpy to trt vn ptints with good prognoss, thr will b young womn who hv bcom mnopusl but hv xcllnt prognoss for long-trm survivl. Mry hs t lst two strong incntivs for wnting childrn. Sh nd Json hd witd to hv childrn for yrs, only to hv hr cncr discovrd just s thy bgn trying to strt thir fmily. In ddition, whn fcing potntilly ftl illnss mny popl, spcilly young popl, considr how thy might lv prmnnt mrk on th world. Hving childrn is on wy to lv such lgcy. s long s prgnncy dos not ffct bowl cncr nd borting th bby dos not improv th prognosis, tough thicl nd clinicl dilmm of ithr chmothrpy is th bst wy of cncr trtmnt is producd. In helping people with cancer find guidance through the decisionmaking process, pastoral counselors can call on the rich heritage of theological ethics in combination with medical ethics. The relational model of covenant forms the foundation for the ethical vision set forth in the Hebrew and Christian scriptures. This covenant is a sacred bond or relationship between human beings and a greater power. Such an ethical vision motivates and guides people to a consideration of the well-being of others and to the stewardship of all life. A theology of God's all-inclusive, unconditional love for creation leads to ethics based on the worth and dignity of all life. This ethical vision requires justice in all relationships and endeavors. In making ethical decisions, we must then consider the good of the community along with the good of the individual. Images of God as inclusive Love and Justice inform the person with cancer and the pastoral counselor as together they seek solutions to difficult ethical dilemmas. Medical ethics has traditionally followed certain principles for decision making. A classic ethical principle in medical decision making is beneficence. Based on the Hippocratic principle, beneficence guides health care professionals to benefit the patient according to their ability and judgment. Some, seeing the paternalism inherent in this model, have placed autonomy at the center of medical ethics. Autonomy, defined as respect for the individual's right to self-determination, has become popular as a guide to medical decision making, especially in the United States. Some ethicists, instead of asking health care professionals to abandon their historical position of beneficence, call for a balancing of this principle with the principle of autonomy. Thus the central values guiding decision making are the patient's well-being and respect for the patient's self-determination. Honesty is another important ethical principle, requiring that health care professionals be truthful in communicating information about treatment options so that people can make informed decisions. There is increasing emphasis on the ethical principle of justice, defined as fair distribution of resources. The issue of the just allocation of resources brings into focus the good of the community as well as the individual. Eric Cassell believes that "autonomy itself implies a social world" and that the emphasis on autonomy in the recent past has obscured the communal aspect of individuality, particularly in academic ethics. Judith Caron asserts that ethics and morality have always "involved a tension between the individual and the community as a whole. In helping people with cancer find guidance through the decisionmaking process, pastoral counselors can call on the rich heritage of theological ethics in combination with medical ethics. The relational model of covenant forms the foundation for the ethical vision set forth in the Hebrew and Christian scriptures. This covenant is a sacred bond or relationship between human beings and a greater power. Such an ethical vision motivates and guides people to a consideration of the well-being of others and to the stewardship of all life. A theology of God's all-inclusive, unconditional love for creation leads to ethics based on the worth and dignity of all life. This ethical vision requires justice in all relationships and endeavors. In making ethical decisions, we must then consider the good of the community along with the good of the individual. Images of God as inclusive Love and Justice inform the person with cancer and the pastoral counselor as together they seek solutions to difficult ethical dilemmas. Medical ethics has traditionally followed certain principles for decision making. A classic ethical principle in medical decision making is beneficence. Based on the Hippocratic principle, beneficence guides health care professionals to benefit the patient according to their ability and judgment. Some, seeing the paternalism inherent in this model, have placed autonomy at the center of medical ethics. Autonomy, defined as respect for the individual's right to self-determination, has become popular as a guide to medical decision making, especially in the United States. Some ethicists, instead of asking health care professionals to abandon their historical position of beneficence, call for a balancing of this principle with the principle of autonomy. Thus the central values guiding decision making are the patient's well-being and respect for the patient's self-determination. Honesty is another important ethical principle, requiring that health care professionals be truthful in communicating information about treatment options so that people can make informed decisions. There is increasing emphasis on the ethical principle of justice, defined as fair distribution of resources. The issue of the just allocation of resources brings into focus the good of the community as well as the individual. Eric Cassell believes that "autonomy itself implies a social world" and that the emphasis on autonomy in the recent past has obscured the communal aspect of individuality, particularly in academic ethics. Judith Caron asserts that ethics and morality have always "involved a tension between the individual and the community as a whole. The number of treatment possibilities for people with cancer continues to increase. Along with the conventional treatments of surgery, radiation, chemotherapy, and hormone therapy, experimental treatments are available for some types of cancer. In addition, there is a plethora of alternative and complementary therapies that many people consider. During the months and years following a cancer diagnosis, many people face repeated choices about treatment. Selecting the most appropriate options may determine survival chances and/or quality of life. Many lives have been saved or lost as a result of the quality of decisions people make concerning their cancer treatments. People with cancer realize that the stakes are high, and thus they may feel deeply conflicted as they face choices among treatment options. In choosing among treatments, people must balance chances for cure against undesired side effects. A year after undergoing extensive chemotherapy and marrow transplantation in treatment of lymphoma, one middle-aged man suffered a recurrence. He agonized over the option of another transplant that promised little chance of long-term survival and that would decrease his quality of life. He wondered if the painful side effects he would suffer with another aggressive treatment were worth the small chance of more time. And he knew that even though this treatment might eradicate the cancer, there was a possibility that he might die from the side effects of the treatment. For womn who is lrdy prgnnt whn bowl cncr is dignosd, thr r som difficult dcisions. Th stg of th fotus nd th stg of th cncr will dtrmin wht cn b offrd. Sh could opt for trmintion to prmit mor ggrssiv trtmnt-dpnding on hr viws on bortion nd on how much tht prticulr prgnncy mns to hr. Or sh could choos to kp th child nd tilor th trtmnt to fit in with hr prgnncy. This might mn ccpting tht som of th mor ffctiv trtmnts r not vilbl until ftr hr child is born. Som suppos tht in th priod of third trimstr Mry N. nds mstctomy or chmothrpy rthr thn rdition thrpy, which is hrmful to th unborn child t ny stg of dvlopmnt, would b dlyd until ftr it ws born. Sh cn lso choos to dly trtmnt until th first 3 months hv pssd, thn hv chmothrpy which is not ggrssiv nough to hrm th bby, but might b lss dmging to th cncr. Sh cn dly trtmnt until ftr th bby is born, which might put hr own lif t risk. Or sh could choos to hv n bortion, knowing tht th nti-cncr drugs might dmg hr ovris nd mk hr infrtil. Thr is no vidnc tht hving n bortion improvs th prognosis, but it mks trtmnt sir. Whtvr th dcision, sh will nd plnty of motionl support. But it is hr dcision. To gt closr to th dcision tht will solv h dilmm lt us tk look t th contmporry mthods of bowl cncr. Diffrnt typs of trtmnt r vilbl for ptints with bowlcncr. Som trtmnts r stndrd (th currntly usd trtmnt), nd som r bing tstd in clinicl trils. Bfor strting trtmnt, ptints my wnt to think bout tking prt in clinicl tril. trtmnt clinicl tril is rsrch study mnt to hlp improv currnt trtmnts or obtin informtion on nw trtmnts for ptints with cncr. Whn clinicl trils show tht nw trtmnt is bttr thn th stndrd trtmnt, th nw trtmnt my bcom th stndrd trtmnt. (Cuzick, t l. 2005) Trtmnt options for prgnnt womn dpnd on th stg of th diss nd th g of th ftus. Thr typs of stndrd trtmnt r possibl for Mry N.: Surgry Most prgnnt womn with bowl cncr hv surgry. Som of th lymph nods undr th rm r usully tkn out nd lookd t undr microscop to s if thy contin cncr clls. vn if th doctor rmovs ll of th cncr tht cn b sn t th tim of surgry, th ptint my b givn rdition thrpy, chmothrpy, or hormonw thrpy. Trtmnt givn ftr surgry to incrs th chncs of cur is clld djuvnt thrpy. Rdition thrpy Rdition thrpy is cncr trtmnt tht uss high-nrgy x-rys or othr typs of rdition to kill cncr clls. Thr r two typs of rdition thrpy. xtrnl rdition thrpy uss mchin outsid th body to snd rdition towrd th cncr. Intrnl rdition thrpy uss rdioctiv substnc sld in ndls, sds, wirs, or cthtrs tht r plcd dirctly into or nr th cncr. Th wy th rdition thrpy is givn dpnds on th typ nd stg of th cncr bing trtd. Rdition thrpy should not b givn to prgnnt womn with rly stg bowl cncr bcus it cn hrm th ftus. For womn with lt stg bowl cncr, it should not b givn during th first 3 months of prgnncy. Thrfor, rdition thrpy cn b pplid for Mry N. s sh is sh is lrdy on hr sixth month of hr prgnncy. Howvr, th stg of th cncr should b considrd bfor. Chmothrpy Chmothrpy is cncr trtmnt tht uss drugs to stop th growth of cncr clls, ithr by killing th clls or by stopping th clls from dividing. Whn chmothrpy is tkn by mouth or injctd into vin or muscl, th drugs ntr th bloodstrm nd cn rch cncr clls throughout th body (systmic chmothrpy). Whn chmothrpy is plcd dirctly into th spinl column, n orgn, or body cvity such s th bdomn, th drugs minly ffct cncr clls in thos rs (rgionl chmothrpy). Th wy th chmothrpy is givn dpnds on th typ nd stg of th cncr bing trtd. Chmothrpy should not b givn during th first 3 months of prgnncy. Chmothrpy givn ftr this tim dos not usully hrm th ftus but my cus rly lbor nd low birth wight. In trms of this condition, chmothrpy is optionl for Mry N. Nw typs of trtmnt r bing tstd in clinicl trils. Ths includ th following: Hormon thrpy Hormon thrpy is cncr trtmnt tht rmovs hormons or blocks thir ction nd stops cncr clls from growing. Hormons r substncs producd by glnds in th body nd circultd in th bloodstrm. Som hormons cn cus crtin cncrs to grow. If tsts show tht th cncr clls hv plcs whr hormons cn ttch (rcptors), drugs, surgry, or rdition thrpy r usd to rduc th production of hormons or block thm from working. Th ffctivnss of hormon thrpy, lon or combind with chmothrpy, in trting bowl cncr in prgnnt womn is not yt known. nding th prgnncy dos not sm to improv th mothr's chnc of survivl nd is not usully trtmnt option. If th cncr must b trtd with chmothrpy nd rdition thrpy, which my hrm th ftus, nding th prgnncy is somtims considrd. This dcision my dpnd on th stg of cncr, th g of th ftus, nd th mothr's chnc of survivl. Mary N may turn to alternative treatments as many in her situation would do. Normally, such people do it for a variety of reasons. It is possibly that they have no other options of conventional or experimental therapies; they do not trust conventional or experimental treatments; alternative therapies appear to offer greater benefits with fewer side effects; they want more direct control over their lives than conventional medicine offers; they want these treatments along with conventional therapies in order to feel that they have done everything they can do. People who choose alternative cancer treatments are usually well-educated and reflect the social concerns of personal responsibility, caring for the environment, and prevention of disease. Whether to choose alternative therapies may pose a difficult ethical dilemma because few of these therapies have been tested in scientific trials, and they may turn out to be costly, useless, or even dangerous. It is often hard to discern whether the people promoting these therapies are exaggerating their claims and taking financial advantage of vulnerable people or whether they are motivated by altruistic concern. Instead of an either-or choice between conventional and alternative therapy, many people choose both. Complementary therapies, including nutritional and psychosocial treatments along with conventional treatment, are increasingly becoming the focus of research studies. These studies seek to determine improvement in quality of life as well as prolonged survival rates. In the meantime, people with cancer often feel overwhelmed as they try to explore all the treatment possibilities and to examine their claims. Family and friends may add to the stress by their recommendations of therapies they have heard or read about. Mary N. may feel that she is trapped in a maze with no guiding compass to direct them to the right paths. Pastoral counselors can play an important role in helping people to discover that compass within themselves. An important pastoral intervention is to help people clarify the theological, philosophical, cultural, and personal values that affect ethical decision making. Chaplains and pastoral counselors can serve as facilitators of open communication and mediators when the values of people with cancer clash with the values of their families or of the medical staff. Within the context of these value systems, people wrestle with questions concerning cost of therapies versus benefits. Lt us now tk closr look to th dvntgs nd disdvntgs of chmothrpy in Mry N's sitution. For womn who lrn thy hv bowl cncr whil prgnnt, nw study provids rssurnc tht chmothrpy pprs sf during th scond nd third trimstr. Bowl cncr is rr during prgnncy. It is stimtd tht lss thn four prcnt of womn r dignosd with bowl cncr during this tim. But whn it dos occur, cncr trtmnts must b givn in wy tht will protct th ftus whil not compromising th womn's own chnc for survivl. Th fficincy of chmothrpy during prgnncy cn b viwd through th prcticl situtions tht hv tkn plc in th world mdicl prctic. For xmpl, group of British rsrchrs rviwd rcords from fiv hospitls in London to gthr informtion bout womn who hd rcivd chmothrpy for bowl cncr whil prgnnt. Thy idntifid 63 womn who wr prgnnt t th tim thir bowl cncr ws dignosd; 28 of ths womn hd chmothrpy whil prgnnt. Th womn wr btwn 28 nd 42 yrs of g. ll wr btwn 5 nd 29 wks prgnnt. (Mirick, Dvis, Thoms, 2005) Svntn womn hd surgry whil prgnnt. Four hd surgry ftr dlivry. Svn womn hd nodjuvnt chmothrpy (trtmnt givn bfor surgry) to rduc tumor siz or following dignosis of inflmmtory bowl cncr, nd 17 womn rcivd djuvnt chmothrpy (trtmnt givn ftr surgry.) Four womn rcivd chmothrpy to trt mtsttic diss. ll of th womn wr btwn 15 nd 33 wks prgnnt; 22 strtd chmothrpy during th scond trimstr nd fiv during th third trimstr. On womn rcivd chmothrpy in th first trimstr. Sh ws not wr sh ws prgnnt t th tim, nd ltr hd miscrrig. Th rcords indictd tht chmothrpy did not cus ny bnormlitis in th childrn tht wr born. Bsd on thir findings, th rsrchrs concludd "womn should not b dnid th potntil bnfits of chmothrpy bcus thy r prgnnt t th tim of thir bowl cncr dignosis." (Mirick, Dvis, Thoms, 2005) Othr rsrch bout chmothrpy during prgnncy lso point to th fct tht th procdur is worth doing. Of th 27 childrn includd in survy of thir prnts or gurdins, ll but thr wr rportd hlthy nd dvloping normlly. Th only xcptions wr on child with Down's syndrom, which Dr. Gwyn sid hs nothing to do with chmothrpy, nd two childrn with ttntion dficit disordr, which is not uncommon. On qustion tht rmins unnswrd is whthr th frtility of ths childrn will b ffctd, bcus th oldst child from this study is only 13 yrs old. Howvr, th rsrchrs r ncourgd by th rsults of study of prgnnt ptints with lymphom who wr trtd with chmothrpy. Thir childrn hv bn monitord for mor thn 18 yrs, nd som of thm hv lrdy dmonstrtd frtility. (Kufmnn t l., 2003) Prgnncy, with its combintion of physicl nd hormonl chngs, is hrd nough on womn's body. Th lst thing mothr-to-b nds is th ddd compliction of cncr. Unfortuntly, bout on in vry 1,000 prgnncis dos coincid with cncr. Oftn, ths womn r dvisd to trmint thir prgnncis, but mny womn r bl to undrgo ffctiv trtmnt for thir cncr nd dlivr hlthy bby. "W continu to s ptints, nd th first thing tht hs bn rcommndd to thm is tht thy trmint th prgnncy. nd for som popl, tht my b thir choic, nd tht my b wht thy wnt to do," sid Richrd L. Thriult, D.O., profssor in th Dprtmnt of Bowl Mdicl Oncology t Th Univrsity of Txs M.D. ndrson Cncr Cntr. (Grhm t l., 2004) "Dpnding on th stg of thir cncr nd thir mdicl hlth, nding th prgnncy my b pproprit," ddd Krin M..H. Gwyn, M.D., n ssistnt profssor in th Dprtmnt of Bowl Mdicl Oncology nd th Dprtmnt of pidmiology, "but it is not lwys ncssry." Prgnnt womn cn undrgo biopsis nd vn b trtd for cncr with chmothrpy. (Grhm t l., 2004) Th cncr most commonly dignosd during prgnncy is bowl cncr, followd by crvicl cncr, thn lymphom nd thyroid cncr. Lss common r lukmi nd mlnom. With th xcption of most css of crvicl cncr, prgnncy nd cncr trtmnt r not mutully xclusiv. "In crvicl cncr, th stndrd trtmnt is surgry [rdicl hystrctomy] nd rdition," Dr. Thriult sid. "Th issu is tht th ftus is going to di from th trtmnt, xcpt in unusul circumstncs whr th cncr is dignosd rly through Pp smr nd you r bl to rmov ll th cncrous tissu with crvicl cor biopsy nd mintin th prgnncy nd dlivry." Th incidnc of bowl cncr concurrnt with prgnncy is xpctd to incrs s mor womn dly childbring nd s mmmogrphic scrning incrss. Th Ntionl Cncr Institut's Survillnc, pidmiology, nd nd Rsults Progrm's Cncr Sttistics Rviw found tht womn who hv thir first full-trm prgnncy ftr g 30 hv two to thr tims highr risk of bowl cncr thn womn who hv thir first prgnncy bfor g 20. mong th womn in th M.D. ndrson cohort, th mdin g is 33, nd th oldst womn mong th ptints is 42. s rsult, Dr. Thriult urgs incrsd suspicion of ny chngs in th bowls of prgnnt womn in thir 30s or 40s. Whn n nomly is found, Dr. Gwyn rcommnds tht obsttricins sk th hlp of cncr spcilists rthr thn kp th burdn of dignosis on thmslvs. ccurtly rding mmmogrm or n ultrsound of prgnnt womn's bowl is difficult nd rquirs xprinc, s dos intrprting th rsults of biopsy from lctting bowl. (Brown, Lffll, 2003) Chmothrpy cn cus n rly mnopus, which of cours mns th womn will b infrtil. Th closr sh is to th nturl mnopus whn trtmnt strts, th highr th risk tht th chmicls will stop hr priods prmnntly. Th vrg g of mnopus is 51 nd th risk of chmothrpy-inducd mnopus for womn of 45 is 80 to 90 pr cnt but 15 to 20 pr cnt for 35-yr-old, dpnding on th drugs usd. (Brown, Lffll, 2003) It is difficult to b sur which womn will bcom post-mnopusl s rsult of th chmothrpy, but it is importnt to considr this s possibility bfor trtmnt strts. nd whn mking dcision it is good id to b ntirly clr bout how importnt th chmothrpy is in prvnting rcurrnc. If th doctor sys tht chmothrpy will hlv th chnc of th cncr coming bck it sounds prtty convincing. But if th risk of rcurrnc is only 4 or 5 pr cnt, tht mns th chmothrpy rducs th risk to 2 or 2.5 pr cnt, nd th diffrnc in risk might not wrrnt th pric for som womn. In addition to the social ethical concerns regarding the just allocation of limited resources, environmental concerns are also important to biomedical ethics based on a theology of the goodness of all creation. Guided by this theological ethical vision, pastoral counselors advocate a medical decision-making process in which all involved, including managed care organizations, are motivated by the best interests of individuals and by a careful stewardship of resources, not by an incentive to undertreat in order to maximize profits. In addition to articulating principles that apply to individual cases, those involved in medical decision making need to address the influence of institutional structures on the allocation of health care resources. We must ensure that the health care system affords access for all and that it exercises responsible stewardship of the earth's resources. 15 In th nd, if prgnnt womn is found to hv bowl cncr, chncs r it will b n ggrssiv cncr. Tht unfortunt fct is not rltd dirctly to th prgnncy but rthr to th g of th ptints. Th tumors occurring in prgnnt womn r no diffrnt thn th tumors occurring in othr young womn, but bowl cncr in young womn is histologiclly ggrssiv diss, so it's mor th g of th ptint thn hr prgnncy sttus tht ffcts th tumor's growth nd prognostic mrkrs. Tking into considrtion th nlysis md in bov nd obsrvtion of Mry N, I suggst tht it will b rsonbl to undrtk chmothrpy. Bibliogrphy: 1. (1999). Tmoxifn thrpy for cncr nd ndomtril cncr risk. Journl of th Ntionl Cncr Institut, 91 (19), 1654-62. 2. Brown, Z. & Lffll, L.D. (2003). 100 Qustions nd nswrs bout Bowl Cncr during prgnncy. Sudbury, M: Jons nd Brtltt Publishrs. 3. Cncr Rsrch UK (2002). Bowl Cncr: Spot th Symptoms rly (Lflt). London: Cncr Rsrch UK. 4. Cuzick, J., Powls, T., Vronsi, U., Forbs, J., dwrds, R., shly, S. & Boyl, P. (2005). Ovrviw of th min outcoms in bowl cncr prvntion trils. Th Lnct, 361, 296-300. 5. Grhm, J., Rmirz, ., Lov, S., Richrds, M. & Burgss, C. (2004). Chmothrpy in cncr trtmnt. British Mdicl Journl, 324, 1420-22. 6. Kufmnn, M., Jont, W., Blmy, R., Cuzick, J., Nmr, M., Foglmn, I., d Hs, J.C., Schumchr, M. & Surbri, W. (Zoldx rly Bowl Cncr Rsrch ssocition (ZBR) Trilists' Group) (2003). Survivl nlyss from th ZBR study: Gosrlin (Zoldx) vrsus CMF in prmnopusl womn with nodpositiv bowl cncr. uropn Journl of Cncr, 39 (12), 1711-17. 7. Mirick, D.K., Dvis, S., Thoms, D.B. (2005). ntiprspirnt us nd th risk of bowl cncr. Journl of th Ntionl Cncr Institut, 94 (20), 1578-80. NHS Cncr Scrning Progrmms wbsit: www.cncrscrning.nhs.uk. Read More