Amy Harmon | International Herald Tribune

Her latest mammogram was clean. But Deborah Lindner, 33, was tired of constantly looking for the lump.

Ever since a DNA test had revealed her unusually high chance of developing breast cancer, Lindner had agonized over whether to have a mastectomy, a procedure that would reduce her risk by 90 percent.

She had stared at herself in the mirror, imagining the loss of her familiar shape. She had wondered, unable to ask, how the man she had just started dating would feel about breasts that were surgically reconstructed, incapable of feeling his touch or nursing their children.

But she was sure that her own mother, who had chemotherapy and a mastectomy after a bout with the cancer that had ravaged generations of her family, would agree it was necessary.

"It could be growing inside of me right now," she told her mother on the phone in February, pacing in her living room here. "We could find it any time." She added, "I could schedule the surgery before the summer."

But no approval came.

"Oh, sweetheart, let's not rush into this," said her mother, Joan Lindner.

Joan Lindner, 63, is a cancer survivor. Her daughter, by contrast, is one of a growing number of young women who call themselves previvors, because they have learned early that they are genetically prone to breast cancer, and have the chance to act before it strikes.

As they seek to avoid the potentially lethal consequences of a mutant gene, many of them turn to relatives who share its burden. But at a moment when a genetic test has made family ties even more tangible, they are often at their most strained.

Parents who have fought cancer typically have no experience with the choices that confront their children, and guilt over being the biological source of the problem can color their advice. Siblings and cousins who carry the risk gene evangelize their own approach to managing it, while those who dodged its inheritance seem unqualified to judge.

Even as she searched for her own answer in the year after her DNA test, Deborah Lindner, a medical resident, found herself navigating her family's strong and divergent opinions on the imperfect options that lay before her.

Her father, who once feared that he would lose his wife to cancer, encouraged the surgery. Her sister reminded her that cancer might be cured in a few years if she could wait. Her aunt said she hated to see her niece embrace a course of action akin to "leechings of the Dark Ages." A cousin declined even to take the DNA test.

But it was her mother's blessing that Deborah most eagerly sought. Joan Lindner, who had passed her defective gene to her daughter, wanted to will her more time. When she had her own breasts removed, she had been married for 27 years and had raised two daughters. Now Joan Lindner could not shake the fear that her daughter might trade too much in her quest for a cancer-free future. What if taking such a radical step made it harder for Deborah to find someone special and become a mother herself?

"I have this amazing gift of knowing my risk," her daughter told her over the phone that winter night, gazing out over the frozen city from her apartment on the 38th floor. "How can I not do anything about that?"

The Lindners share a defective copy of a gene known as BRCA1 (for breast cancer gene 1) that raises their risk of developing breast cancer sometime in their lives to between 60 percent and 90 percent.

Only 30,000 of more than 250,000 American women estimated to carry a mutation in BRCA1 or a related gene, BRCA2, have so far been tested. But their numbers have doubled in the last two years and, with a sharp increase in genetic testing, are expected to double again in the coming one.

About a third opt for preventive mastectomies that remove the tissue where the breast cancer develops.

A majority have their ovaries removed, halving their breast cancer odds while decreasing the risk of highly lethal ovarian cancer, to which they are also prone. Some take drugs that ward off breast cancer. Others hope that frequent checkups will catch the cancer early, or that they will beat the odds.

Their decisions, which require weighing an inborn risk against other life priorities, are highly individual. But with DNA forecasts of many other conditions on their way, BRCA carriers offer the first clues for how to reckon with a serious disease that may never arise - and with the family turmoil that nearly always does.

Deborah Lindner's sister, Lori French, got her results first.

Long ago, before she knew about the DNA test, French, 37, had resolved to have her breasts and ovaries removed by the age of 40 to avoid the family cancer. Nor did she want reconstructive surgery, having seen her mother struggle with the pain and cosmetic disappointment of hers.

"Plan on it," she had told her husband before they got married a decade earlier. "I'm going to get old and have big hips and no breasts."

The envelope with the test results that French opened with shaking hands in the summer of 2005 offered a reprieve.

She and her husband sobbed, hugging each other in the knowledge that she was free of the genetic defect. While she still had the 12 percent chance any woman has of developing breast cancer, she could not have passed on the steep BRCA risk to either her daughter or son.

"It's done!" French told her family. "In our line, it's ended."

For years, the sisters had united in a common dread. Now it was Deborah's alone. It could have been either, neither or both of them - each sister, she knew, had a 50 percent chance of inheriting the defective gene from their mother, dictated solely by a roll of the genetic dice.

In the weeks that followed, Deborah fought off pangs of jealousy and the fantasy that fate could somehow be rearranged.

"She already has a husband, she already has kids," Deborah thought about her sister on morning runs along Lake Michigan.

She enrolled in a stepped-up surveillance program that required alternating mammograms and sonograms with MRIs every six months.

But on the mornings of her appointments, and at unpredictable moments in between, she was overwhelmed with fear. Often, she would examine her breasts every other day.

"It's taking over my mind," she told Erin King, a close friend and fellow resident in the obstetrics and gynecology program.

King, 33, who had breast implants for cosmetic reasons, and another resident friend were proponents of pre-emptive surgery.

"Get them off and get new ones," they told her. "They'll be awesome and perky and cute."

But they sympathized with her distress at the appearance of traditional reconstruction, with skin grafts molded into a fake nipple that can never quite match the texture of a real one and the areola simulated by a tattoo.

Over Thanksgiving 2006 at her parents' winter home in Florida, Deborah Lindner ran through her risk analysis. Her father, Philip Lindner, listened and nodded.

Mammograms and ultrasounds, she noted, may miss more than half of cancers in younger women with denser breasts.

Magnetic resonance imaging tests are more reliable but produce more false positives, which can lead to unnecessary biopsies and worry. And it is not yet clear that early detection improves survival rates in women with BRCA mutations.

"You can't argue with statistics," said Philip Lindner, a financial executive. "You don't want to get cancer and then say, 'I wish I would have done thus and so.' "

Joan Lindner agreed that it was important to know the risks. But not knowing them could be a luxury, too. Had she had the same options as her daughter, would she have found a man and had a family? It might have altered her whole life.

Deborah Lindner began to seek support elsewhere. A genetic counselor gave her a brochure for Bright Pink, a group of young women who have tested positive for the BRCA genes.

Lindsay Avner, its founder, lived in Chicago, and their meeting over coffee in the hospital lounge one evening in March lasted four hours. Avner, 24, had a prophylactic mastectomy last year.

"You've got to see my breasts," she told Deborah Lindner, escorting her into the bathroom.

Avner's surgeon at Memorial Sloan-Kettering Cancer Center in Manhattan had used a technique that preserved the breast skin and nipples, leaving a scar only under the breast. Deborah, still in her scrubs, said, "Wow."

She met with Geoffrey Fenner, the chief of plastic surgery at Evanston Memorial Hospital one evening in mid-April.

If she could find a surgeon to perform the mastectomy, Fenner said, he would perform the reconstruction.

Deborah announced her intention to have surgery in a long e-mail message to family members at the end of April.

"I want to share with you what I feel is the right answer for me," she wrote.

Like anyone who carried the defective gene, she might never get cancer, she acknowledged. Or she might only get it when she was old. "But I'm not a gambler," she wrote.

Deborah scheduled the double mastectomy with Dr. D.J. Winchester at Evanston Northwestern hospital for the last weekend in June, three days after her medical board exam.

Her insurance agreed to pay after requesting a letter of support from her surgeons. There would be just enough time to recover before she began practicing in the fall.

The surgery and reconstruction took seven and a half hours, twice as long as the doctors had expected. The incisions were small, Winchester explained when he came out, and hidden under the breast, so it had taken a long time to scrape out all the breast tissue.

Then Joan Lindner rode up in the elevator with her daughter, still unconscious from the anesthesia.

As they arrived at their floor, Deborah opened her eyes.

"Mom," she said, and managed a small smile.