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Scot: Hey, Mitch. If you found a lump someplace on your chest, what would you do?

Mitch: Like, on the chest? Under?

Scot: Yeah. Maybe under the chest, under your arm, or by your nipple, or just anywhere on the chest, if there was a lump there, like a marble.

Mitch: I don't know. I legitimately would just assume it was, I don't know, a cyst or something like that. I'd probably just wait and see how it turned out, see if it went away. Yeah, I don't know.

Scot: That's a pretty standard man policy right there. It's just, "Well, let's see what happens to this thing. Maybe it'll just go away."

Troy, how about you? I mean, you're a doctor, so you're probably going to have a different answer.

Troy: Well, that's the problem. I am a doctor, so I tend to either think everything is cancer or I just ignore it. So I would probably do one of those two things. And like Mitch said, it would probably be based on what it did. If it started getting larger or more red and kind of inflamed around that area, I'd probably get it checked out, but again, I'd probably put it off for a while before I did something.

Scot: Yeah. Would you ever think it was breast cancer though?

Troy: I don't think I would. It's just not something I think about in terms of as a man.

Scot: That's not unusual. A lot of guys don't even know breast . . . A lot of people, I should say, don't even know that male breast cancer is a thing. They think it's a woman's disease. Another common thing is, "Men don't have breasts, so how am I going to get breast cancer? I have a chest. I don't have breasts."

Mitch: Okay. I'm sorry. That's fine.

Scot: "And I'm a manly man, so how can I get a woman's disease of breast cancer?" So here's the 30-second part of the podcast. If you're a man and you find a lump on your chest, you should have it looked at. While male breast cancer is rare, it is deadly if ignored. And it's really treatable if it's caught early.

So this is interesting. The time it generally takes from a man finding a lump to seeing a doctor is about 12 to 14 months. It takes over a year from noticing that lump.

So the 30-second version is if you find a lump, have it looked at. Don't talk yourself out of it. Don't give into you and your society's perceptions about men who get breast cancer and what those are. But if you want to learn more, then stick around.

This is "Who Cares About Men's Health," providing information, inspiration, and a different interpretation of men's health. Today's episode is a "Men's Health Essentials" episode, a strange one because it's about male breast cancer, something that a lot of guys don't even think is a thing.

I'm Scot Singpiel. I bring the mics and the BS. Welcome to the studio, actually remote, the MD to my BS, emergency room physician Dr. Troy Madsen.

Troy: Hey, Scot. This is a great topic. I'm glad we're learning about it.

Scot: And balancing us all out is Mitch Sears.

Mitch: Oh, I like that. But a year? A year you have a lump and we don't go talk about it?

Scot: I don't know.

Mitch: Okay. All right. I'm excited.

Scot: And we're super lucky to have an expert with us. Dr. Matt Covington is an expert in cancer imaging, and he specifically focuses on early detection and accurate staging of breast cancer. From Huntsman Cancer Institute, Dr. Covington, welcome to the show.

Dr. Covington: Thank you, Scot. I'm really happy to be here.

Scot: All right. So the first thing I want to know is I have breast tissue, huh? What? Why didn't anybody ever tell me this?

Dr. Covington: Yes. I think that's news to a lot of men. We assume that we don't have breast tissue. I think we like to think that we have skin and nipple and muscle, and that there's no breast tissue in between. But the truth is that there is a small amount of breast tissue in every male.

And as we'll talk about today, sometimes that breast tissue can cause problems and sometimes it can cause lumps that should not be ignored. And what I really hope to accomplish today is to convince everybody that if a man feels a lump in your chest, it needs to be evaluated.

Scot: Yeah. So why is the rate of mortality so high for men who get breast cancer? What do we know about that?

Dr. Covington: The mortality rate is high, and it's much higher than it should be. The primary reason for that is that male breast cancer is often diagnosed late. There are a few reasons for that that we could get into, but it's that late presentation to seeking imaging. It's that delay in getting a tissue diagnosis of breast cancer that allows those breast cancer cells to spread from where it started in the breast, often into the lymph nodes, and then unfortunately often outside of the lymph nodes to cause metastatic disease.

Mitch: One of the questions I guess I have here is how much higher is the mortality rate then? I understand cancer progresses in phases and after a certain point, it's going to be really hard to treat it, but if we're waiting 12 to 18 months, how much higher is the mortality rate in men?

Dr. Covington: So what I can tell you about the mortality rate of male breast cancer is that unfortunately, five years after diagnosis, about half of all men will have passed away from the disease.

Mitch: Wait. Half?

Dr. Covington: Yeah. We often look at five-year survival for all types of cancer, and in the case of male breast cancer, the five-year survival is something around 40% to 65%.

Scot: And is that because we are waiting so long, or is it a more insidious type of cancer than what women get?

Dr. Covington: You're onto something with both of those statements that you said. In some cases, the biology of the breast cancer is actually a little bit more aggressive, we think, in males. That principle translates the same across many cancers. If you're someone in the minority in terms of getting a cancer, if you do get that cancer, often it will be a little bit more aggressive. That's not necessarily unique to breast cancer.

The other reason why mortality is delayed is that you lose the window to cure the cancer if you wait too long. It's the same game we play with female breast cancer, and that's why screening exists for breast cancer. Things like screening mammography exist because breast cancer is curable if you catch it early enough.

That same principle applies to men. Unfortunately, fewer men are presenting with curable breast cancers because they're simply not early. They've already started to spread by the time we even realize it's there.

Troy: I was going to say, just to put that in perspective, what's the five-year mortality rate for breast cancer in women?

Dr. Covington: So that depends a lot on the stage of diagnosis, but overall, you're looking at something like 80% to 90% survival at 5 years. But that five-year survival will look similar to men if you're considering advanced stage cancers, meaning Stage 4 where it's distant, where it has already spread throughout the body. Survival for those women will look very similar to that of men.

Scot: It's just they're doing a much better job of getting women screened. Women are doing a much better job and there's a lot more awareness.

Dr. Covington: That's correct. Well, screening for breast cancer doesn't exist for most males. That's true. You have to have certain genetic risk factors. You have to have some idea that you're at high risk to even undergo some sort of screening.

That's different with women where there is recommended national screening. Starting at age 40 is what we typically recommend. For men, screening would simply be paying attention to your own body. Did you notice a lump? If so, it needs to be evaluated.

Scot: I like that. I like that linear relationship. It's easy. I almost want to put that in Caveman. "Notice lump, get evaluated."

Dr. Covington: I think that could be a great public campaign to raise awareness, yes.

Scot: That's four words. That's perfect.

Troy: That's too big a word. Just say, "See lump, get checked."

Scot: "Go doctor."

Troy: "Go doctor." I'm curious though, Matt, as you're talking about this. And obviously, it sounds like screening is a huge part of it. There are very clear screening guidelines for breast cancer in women, certainly, that don't exist in men because the disease is so rare. But with that being said, we do talk about breast self-exams. Women have been counseled to do it. I've heard evidence has been mixed on how helpful that actually is as identifying things. Should men be doing self-exams regularly feeling for lumps and bumps, or what are your recommendations there?

Dr. Covington: So I think it's definitely a good idea to pay attention to your body. And the breast is not the only area where self-exam could potentially save your life when we're talking about men's health, particularly testicular self-exam. If you notice a lump on your testicle, that's probably the most likely way that you'll ever detect that you have testicular cancer. The same is true with the male breast.

Now, let me frame this a little bit. If anybody has a mastectomy, even if, say, a woman has breast cancer and that it's treated with mastectomy, meaning that the breast is removed, after the mastectomy happens, how do we screen those patients? That's a question we can ask ourselves. The answer is self-exam and clinical breast exam.

And the reason why you typically stop doing mammography after the breast has been removed is that if there is a cancer present, you're going to feel it. You don't have all of that breast tissue that can possibly hide it, and that is essentially the situation that men are in. You simply don't have a lot of tissue. There's skin, a little bit of fat, or some people might have a little bit more fat. There's a lot of variation there.

Scot: Quit looking at me like that. It's just not cool. I'm not going to have doctors in the studio anymore.

Dr. Covington: For the record, I was not looking in your direction.

Scot: Okay.

Dr. Covington: But what that means is you have a really high likelihood of actually finding the breast cancer early if you're paying attention.

Scot: So you're telling us that there really aren't any other symptoms. It's really just kind of self-exam, lumps. Am I hearing that correctly?

Dr. Covington: So that will definitely be the most common symptom of male breast cancer, is that you've noticed a new lump. Other symptoms can include things like nipple discharge. I would hope if a man starts having anything clear or bloody . . .

Mitch: It'll probably go away.

Dr. Covington: . . . especially blood from the nipple, get that checked out. Scaling of the nipple, that's something you might not think about. If your nipple is getting pulled in, that's something you might not always think about as a sign of breast cancer. Or if you see changes of the skin over your chest like redness, dimpling, thickening, things like that, that can also be a sign of male breast cancer.

But by and large, it will typically present with some kind of lump. Whether it's painful or not does not help you know whether it's breast cancer or not. So don't use a lack of pain as a reason why this is not a breast cancer.

Mitch: Is anyone else just casually feeling themselves up right now to see if they have anything?

Scot: Well, I would, but I don't know where to feel. Is there any particular place I should be feeling?

Dr. Covington: Definitely, something we need to talk about is feeling behind the nipple. And why I raised that is we absolutely need to discuss something called gynecomastia. And that's a little bit of a complicated term, but it's very important for our discussion, and let me explain why.

Gynecomastia is by far the most common cause of a lump in a man. If you feel a lump, typically, it's going to be gynecomastia. In fact, to the degree that a lot of doctors will probably automatically assume that it will be gynecomastia, but that would be a mistake. We don't want to do that.

Let me talk about gynecomastia, if I could take a moment.

Scot: Yeah. I hope you're going to tell me what it is.

Dr. Covington: Yes.

Scot: Okay. Good. Because right now it's just a big word that I'm afraid of.

Dr. Covington: So, first of all, gynecomastia is not a tumor or a cancer. It is simply an increase in the amount of breast tissue that a male can have. And it's most common in men at two phases in life.

One is puberty, and a lot of teenagers when they're going through puberty get a little bit of swelling and tenderness behind the nipple. That is not uncommon, and it happens because hormone levels are changing during puberty.

It also is very common in men . . . and I do mean common, we see this all the time in the breast imaging clinic . . . in older men often on some sort of blood pressure, cardiac, or mental health medication. And some of those medications also cause breast enlargement to increase a little bit, and that usually will present with swelling behind the nipple.

That's usually very soft. It has a very typical feel for people who are used to identifying between gynecomastia and breast cancer, such as a breast radiologist or a breast surgeon.

And it is what we need to make sure a lump is. We want to see that your lump is gynecomastia because that means it's not cancer. The way to do that is a little bit with physical exam. If there's a really hard mass, that suggests it could be more of a cancer instead of gynecomastia. But also, a mammogram can help us here. And we need to talk about that, that men do get mammograms.

Scot: I still, though, don't know . . . So I'm feeling around the nipple for a hard . . . I still don't know where I'm supposed to feel, I guess.

Dr. Covington: So feel the entire chest. It doesn't take that long. It's not that big. You can do it.

Troy: Did you hear that?

Scot: Yeah. Again, with the looking at me.

Troy: It's not that big.

Scot: I'm going to have to go back to the gym. I'm not as swole as I thought I was, I guess. All right.

Troy: Yeah. This will only take you about two seconds, Scot.

Scot: Wow.

Troy: Hey, I'm just reaffirming what he said.

Scot: Yeah. I'm going to go do some pushups, see if I can beef things up. Troy, you have a question, right?

Troy: My question is, as we're talking about this, I'm hearing this, and certainly any time you hear about cancers and 50% mortality at 5 years, it really raises a lot of concerns. So I'm wondering are there certain people who should be concerned about this more than others? Meaning are there certain people with certain body types, risk factors, such as family history of breast cancer in women, things like that, testosterone therapy? Anything in particular where that's going to increase a man's risk of breast cancer?

Mitch: Or even if someone has a lot of extra weight and maybe they have more fat on their chest or something, is that something too?

Dr. Covington: Those are great questions. Let's talk about risk factors for male breast cancer. First of all, older age is a risk factor for all cancers, and that includes male breast cancer. Genetic mutations, things like the BRCA gene. The BRCA gene, that's what Angelina Jolie had and why she had a double mastectomy. That was pretty widely covered by the media when that happened. The BRCA gene raises risk for breast cancer in everybody. Whether you're a man or a woman, you're at higher risk if you have that.

Scot: I have a BRCA gene just like . . . Angelina Jolie and I have something in common, guys.

Dr. Covington: I hope you don't have a BRCA gene.

Scot: Oh, I don't have a BRCA gene. Just women have those?

Troy: No.

Dr. Covington: No. Men can have it too, yeah. That's the point.

Scot: Oh, you hope I don't because that would . . . Okay.

Dr. Covington: Absolutely. If you had the BRCA gene, I'd be worried that you could have male breast cancer and other types of cancer, including prostate cancer. You don't want it.

Scot: No, I don't want to have anything in common with Angelina Jolie, I decided.

Dr. Covington: But what that means is if you're a man in a family and you have a lot of women in your family that have had breast cancer, and they have genetic testing and they have the gene, that might be important for you to know about. That's definitely something you should talk with your physician about.

And if it's one of these genes like the BRCA gene, the importance of self breast exam, especially probably seeing a physician and having them do a breast exam every year on you also, is important.

Prior radiation therapy to the chest, that's something that men have. You get other cancers, say lung cancer, lymphomas, different things, melanoma, where you might have had radiation to the chest, that can increase your risk of breast cancer.

Using estrogen, we need to talk about that. Estrogen is used for gender transition, and if a genetic male is using estrogen, that does have a significant increase in breast cancer risk to the point that you might want to consider mammographic screening. There are a lot of ongoing studies about that as we speak. We'll have more information in coming years.

Other genetic conditions are things like Klinefelter syndrome where someone might have an extra X chromosome.

If you've had your testicle removed, say you had testicular cancer and it was removed, that lowers your testosterone levels. That allows estrogen levels to have a little bit more influence on your body. That can increase breast cancer risk.

If you have cirrhosis of your liver, that means end-stage liver disease, and therefore heavy alcohol use can increase male breast cancer risk.

And let's talk about weight. Being overweight or obese does increase breast cancer risk, but it's not because you might have more fat in your breast. It's because that actually increases the amount of estrogen in your body. Having more fat allows estrogen levels to rise for reasons we don't need to get into. Therefore, excess body weight is a breast cancer risk factor whether you're a man or a woman.

Scot: Man, that plays back into our Core Four that we talk about on the show, which is to be healthy now and later, you should get some activity, your nutrition, sleep, and emotional health. And of course, that exercise and nutrition is to keep that body weight kind of under control. Time and time again, when we talk about numerous diseases, body weight is such a big factor, and especially here with breast cancer it sounds like.

What about something I've eaten or some sort of environmental factors? Are those risk factors as well? Like, maybe men who work under certain conditions?

Dr. Covington: I would say those are not well understood. I can't think of anything specifically in terms of an environmental exposure that would raise your risk of male breast cancer substantially. We pay most attention to genetic mutations that cause breast cancer, like BRCA, as well as family history in terms of estimating someone's risk.

Scot: And then I also read that non-Hispanic Black men, according to the CDC, have a higher risk than other racial or ethnic groups. I just want to confirm that.

Dr. Covington: Yes, I believe that's true. But that doesn't mean if you are not in that subgroup that you should not pay attention or ignore a lump in your breast.

Scot: Yeah. It's just if you are in that group, that's just another reason why . . . The baseline is, "Lump, go doctor." I made it three words, guys.

Troy: I like it. But just to clarify, now that we've really simplified it, "Lump, go doctor," when you talk about a lump, what do you mean by a lump? If I feel on my chest, and I feel an area that's maybe the size of a pea and it feels kind of firm, should that concern me? Or is this something larger and it feels like a golf ball, or a marble? At what point should I really be concerned when I'm feeling around there?

Dr. Covington: Here's the key. You want to find cancer when it's the size of a pea or even smaller. So what I would say is if you feel a lump, even if it's only pea-sized, and you're certain it wasn't there before, you think it might be new, don't delay, go see your doctor, see what they think, and let them make that decision on whether this is normal or not. But you don't want to wait until you have something the size of a golf ball in your chest.

Scot: That would be bad.

Troy: So size of a pea. "Lump size of pea, go doctor."

Scot: No, you're making it more complicated. Just any lump. "Lump, go doctor."

Troy: I know. We'll keep it simple. "Lump, go doctor." When you go to the doctor, what are they going to do there? Do you expect they're going to do a mammogram or should I expect a biopsy? What should I be thinking I'm heading toward?

Scot: And specifically, am I going to a primary care physician or something of that nature, or do I go to an expert right away?

Dr. Covington: Typically, you'll be seen by a primary care physician first. If you have a primary care doctor, I would suggest you go see them first.

Scot: Or go to a clinic and get an appointment with a doctor.

Dr. Covington: Correct. And they will do an evaluation. They'll feel that area and see if they can confirm themselves that there is a lump. They'll have some kind of idea from their experience how suspicious that lump might be. And in many cases, they'll probably refer you to come see a breast radiologist, such as myself or one of my colleagues, and we will often start with a mammogram.

We need to talk about mammograms because they are key to diagnosis of breast cancer for both males and females, and they can be performed in males despite what anybody may see.

I just had a conversation recently with my mom explaining that men can get a mammogram, and that was news to her. It is a tool that is very valuable for men, but, for reasons, it seems to be tied very closely to females. That's not necessarily helpful when we're considering male breast cancer, because anybody can get a mammogram and it can be a lifesaving imaging study for anybody.

Troy: See, here I've got to say I'm in the same boat as your mom. I'm surprised to hear that men can get a mammogram too. I'm a pretty thin man, and I'm trying to think to myself, knowing how mammograms are done, how are you going to get my breast tissue in to look at it and actually do a mammogram on it?

Mitch: Yeah. How?

Troy: Logistically speaking here, I don't know how you do it, but it sounds like it's possible.

Dr. Covington: It is possible. Even if a woman has had a mastectomy and had her breast completely surgically removed, it is possible to do a mammogram. You can get enough tissue in the machine to get your images. And mammograms are very powerful tools for diagnosis of male breast cancer. I have yet to see a man come in who cannot successfully have a mammogram completed. It simply works.

Scot: We talked about the amount of time that it usually takes men to go get that lump looked at. Again, 12 to 14 months. And part of it is an awareness issue, I've read pretty widely. I think we've proven that men can get breast cancer, but not necessarily everybody knows that.

But there's also some stigma attached to it. Some of the stigma includes, and I mentioned some of this at the top of the show, they first aren't aware that men can get breast cancer, that men even have breast tissue. We don't have breasts. We have chests. It's a woman's disease. We're embarrassed. We feel like, if we have breast cancer, that makes us less of a man because breasts are generally associated with women.

And then there's that general documented phenomenon that men don't want to show weakness and admit something might be wrong with anything beyond even just getting a breast cancer diagnosis.

What are some of the things that you've experienced with your patients, Dr. Covington, as far as that stigma that may have prevented a man from coming in to see you earlier than they did?

Dr. Covington: I think the primary problem is a lack of awareness of male breast cancer. And the stigma is probably a secondary, but still important problem.

So, first of all, let's just spread awareness. Everybody needs to be aware that men can get breast cancer. In fact, about 1 in 100 breast cancers diagnosed in the United States is found in a male, and that translates to something like 3,000 breast cancers a year in men.

In terms of what I've seen with male patients who come in, first of all, they're often a little bit nervous, and I understand that. Nobody wants to think that there's any chance that they could have a cancer. And when they come in, after seeing a doctor who's ordered a mammogram, they're concerned about the possibility that this could be a cancer.

They often are relieved to find out that what we're actually seeing on imaging is gynecomastia. Like I said, that is the most common scenario, but I have definitely been involved with diagnosing breast cancer in men. And every time this has happened to me, it's a sobering experience.

It is always a little bit of a surprise to the patient themselves. It's typically a surprise to their primary care doctor. This usually isn't as high on people's radar as I think it should be. Again, men can get breast cancer and do. As I said, about 1 in 100 breast cancers will be in males. And unfortunately, I've seen too many males with breast cancer do poorly because of delayed diagnosis and presentation.

I don't want to freak out our listeners on the other hand, though. I don't want every man to be concerned as they listen to this that they have breast cancer because chances are you don't. But what we want to do is raise awareness that it's possible. We want to remind every man that if you feel a new lump in your chest, get it evaluated.

And we want to, as much as possible, drive breast cancer in men to an earlier treatable stage of presentation, meaning that we're finding out about it when it's the size of a pea rather than a golf ball.

That's the point of this, but I don't think anybody needs to go home and be convinced they have male breast cancer just because we're saying it's 1 in 100 breast cancers. It is still rare, but it should not be ignored.

Scot: I want to jump in. So it's great that male breast cancer is rare, right? But it also comes with some downsides, which we've talked about, lack of awareness. What about in the medical community? Is there a chance that I could go to a primary care physician, and just because it is so rare, those physicians are not going to necessarily be able to make the best diagnosis? How can I be sure that I'm getting an accurate diagnosis?

Dr. Covington: It is possible that male breast cancer won't be on the top of the list of a primary care doctor, even if you come in saying, "I have a breast lump." Of course, it's something they'll think about, but they will probably assume it's gynecomastia.

Something that you should pay particular attention to that was suggested is not gynecomastia is if your lump is not directly behind the nipple. That raises the possibility greatly that this could actually be a breast cancer.

Now, I don't want anyone who feels a new lump under their nipple not to have it evaluated again. That's part of a key message of what we're talking about. But especially if you feel something that's not under the nipple, and if you were to be told that that's gynecomastia, that would not be correct.

This is something that you just need a little bit of self-awareness, and it's probably worth asking that follow-up question, "Are you sure? Is there anything else this could be? And why do you think that?" Asking those follow-up questions can do wonders in terms of any health complaint, but including a lump in the breast. "Is there anything else this can be and why do you think this is what it is?"

Scot: And from a communication standpoint, that makes total sense, right? I think we all in our jobs and what we do get into these routines and sometimes don't consider the alternatives until somebody kind of says, "Hey, what about this?" or, "Hey, why do you think that?" And then that forces us to slow down and really kind of consider what's going on. So that follow-up question sounds really important.

Dr. Covington: Right. And also, if you have a lump that a doctor may have said is nothing to be worried about and it continues to enlarge, go back again.

Scot: If it doesn't continue to enlarge then, is that likely not breast cancer?

Dr. Covington: If it doesn't continue to enlarge and you've had some evaluation, whether a physical exam or imaging that's showed it's benign, then I wouldn't get concerned. If it goes away, it's not breast cancer. Breast cancer does enlarge over time if it's not treated.

Scot: Yeah. But it might be moving so slow I might not notice the enlargement. And regardless, I shouldn't be making that call of, "Is it not getting bigger?" I should have a professional make that call.

Dr. Covington: That's correct. But my point is if you're told you have a benign breast mass and you go home and, say, two months later, you are absolutely certain it's gotten bigger, that's when you need to go back and say, "Can we take another look at this?"

Scot: All right, guys. What did we learn today? Troy, what's your takeaway?

Troy: My takeaway is breast cancer is more common than I thought it was in men, and I can get a mammogram.

Scot: Yep. How about you Mitch?

Mitch: "Have lump, go to doctor." I guess that was the thing that's so shocking to me, is I actually have heard of and have had a friend of a friend have male breast cancer. So I was aware that it happened, but I did not realize that it's usually pretty fatal because men get in too late. So I'll be feeling my chest, I guess, on a semi-regular basis, and if I ever feel a lump, I'm going to go in and talk to someone about it.

Scot: That's good. And I love what Dr. Covington said. Just because you find a lump doesn't mean it's cancerous, but you should always get a lump checked out.

And my takeaway is there are a lot of things that are going on inside and outside of our heads as men. If we find that lump that might cause us to not get it checked out in a timely way, whether it's this threat to masculinity or whether it's, "Oh, it's such a rare disease. I'm probably okay. I don't have time to go get it checked out anyway." So fight through that stuff and just go get it checked out.

The other thing I do want to say is lack of awareness is one of the primary reasons, as Dr. Covington said, that men die from male breast cancer, and talking about it is the way to overcome that and any of these stigmas as well.

So what I would love it if you would do is share this podcast and say to somebody you know, "Hey, I listened to this podcast called 'Who Cares About Men's Health,' and they talked about male breast cancer, and it was really, really interesting. You should check it out." Who knows? You might be referring it to somebody who has discovered a lump and this might change their perception of that whole thing.

Dr. Covington, thank you so much for being on the show, and thank you for caring about men's health.

Dr. Covington: Thank you. It was a pleasure to be here.

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If you are considering having breast implants, for whatever reason, how do the new FDA guidelines on breast implants affect you and your decision?

Breast augmentation is near the top of the most cosmetic surgical procedures. Although the number of women who had breast implants fell by one-third in 2020, probably related to COVID-19 pandemic, still 200,000 people had breast implants in the U.S. in 2020, down from the usual 300,000 implants per year. About 75% of the implants are for cosmetic reasons, and the rest are part of reconstruction after breast cancer surgery.

Recently, the FDA took some new steps to improve and strengthen the information guidelines about implants and short- and long-term consequences.

It's hard to know how women want to receive information about the risks of breast implants. They believe that they know the benefits, at least for the persons they believe themselves to be right now. They can't really assess the benefits to the woman they will be at, let's say, 60. However, the assessment of benefits is a completely personal process and will be different from woman to woman. And this includes trans women making the decision to have breast implants.

The risks are harder to communicate. Language is often very medical, numbers are hard to process, and some people don't even want to know the risks.

There are data from a randomized trial of information giving that women who received more information were happier with their decision, were less likely to experience preoperative anxiety, and were less likely to experience postoperative regret. So in the information era, I think more is better.

So what are the new components of these new FDA guidelines? First of all, they aren't exactly new. They've been worked on for several years now, and they went out for public comment and were published back in 2020. However, they became more official in the fall of 2021.

Firstly, the boxed warning, the ominous black box that comes on some package inserts of medications and devices that actually nobody really reads unless you stick it on their nose.

I'm going to quote here the example from the FDA with my own asides put in. "Warning," and this is in a big black box, "breast implants are not considered lifetime devices. The longer people have them, the greater the chances are they will develop complications, some of which will require more surgery.

"Breast implants have been associated with the development of a cancer of the immune system called breast-implant-associated anaplastic large cell lymphoma. This cancer occurs more commonly in patients with textured breast implants than smooth implants. Although the rates are not well defined, some patients have died from this." Okay, that's number two.

Three, "Patients receiving breast implants have reported a variety of systemic symptoms, such as joint pain, muscle aches, confusion, chronic fatigue, autoimmune diseases, and others. Individual patients' risk for developing the symptoms has not been well-established. Some patients report complete resolution of the symptoms when the implants are removed without replacement." Okay, that's the black box.

Well, I would want to know more about the phrase that the implants are not considered lifetime devices. There are no recommendations that breast implants be removed after some certain years, not like IUDs that have a finite effectiveness with recommendations for removal at a certain time.

Eighty percent of women who've had an implant placed still have it at 10 years. Of course, the woman that you are at 25 will not be the woman that you are at 55, and neither are your breasts, as all of us know.

"The chance of complication increases over time." What does that mean? Your surgeon should explain those complications, what they are, how often they happen, and what can be done about them.

The common ones are hard fibrous walls around the implant that can be unnatural-looking and feeling, or rupture of the implant capsule.

The uncommon one is the cancer that's associated with the certain kind of implant with a textured, not a smooth, outer covering. That cancer, which is mentioned in the black box, is called breast-implant-associated anaplastic large cell lymphoma. This is a mouthful, but is lymph cancer that arises over time, rarely.

The incidence in women who have these textured implants is 1 in 3,000 to 1 in 30,000. So it's not common. We have a great interview with Dr. Jay Agarwal on this kind of cancer and breast implants. You can find this interview at The Scope if you want to know more.

"Breast implants have been associated with these systemic symptoms." What does that mean? Some women have experienced symptoms such as pain, autoimmune symptoms, chronic fatigue. In the past, this has been somewhat ignored. But there are some women who've had fewer symptoms after their breast implants are removed. This isn't very well understood, but here it is in the black box.

To help understand the black box warning about breast implants, the FDA has created a model patient decision checklist. I think this is really great if it's given to the woman well in advance so she has time to read it or have someone read it to her and explain it to her. This isn't something to be handed out in the pre-op visit just to sign, the way you sign your permissions to your software like Google or your phone. This should actually be read word for word.

The FDA created this checklist to add to that surgeon's counseling. It is meant to be a springboard for discussion, and the patient will read and check off that they've read it and understood it.

It is long, multiple pages, with places for the patients to sign at the bottom of each topic. It includes who shouldn't have implants, at least at the moment: women who have an infection, women who are pregnant or breastfeeding, women who are having chemotherapy or have a suppressed immune system. It includes more information about the rare lymph cancer and about long-term systemic symptoms.

Actually, the example in the FDA guidelines is a really, really good one. If you're an information junkie like me and you read at, at least, the 12th-grade level, it's great.

The long-term risks of complications are spelled out. The frequency at which these things happen are attached, such as painful scar tissue around the implant reported in 51% of patients, rupture or leaking of the implant 30%, need for reoperation 60%. But those are just the biggies.

It's a really great document. It's what your surgeon should have been telling you anyway, but in the heat of the moment in the office, they might not take the 30 minutes to talk to you about this. And you might not remember. This is a great chance to take it home and read it carefully and bring it back with your questions.

And with the FDA guidelines, there's an updated suggestion about management of breast implant rupture or leakage, that 30% of the time it happens.

And last but not least, there's a card for the patient to keep forever in her wallet or personal records about what kind of implant she has, what it's made from, and when it was placed.

Now, you think you'll remember all this stuff, but you won't. And maybe you'll have them still at 80 and your memory is fading. Your surgeon may have retired or gone on to surgeon heaven. Your medical records may be lost. But at least you have a document about what is existing in your body.

If I had implants, I would laminate mine and put it next to my driver's license or my organ donation card.

I think these are really good steps in the right direction in patient information and decision-making. I know you just want what you want and you wanted it yesterday, but it's a long-term decision with long-term consequences, some good, some not so good. You should take your time and try to get it as right as you can.

Thanks for joining us on the "7 Domains of Women's Health" at The Scope.

Dr. Jones: So you've been very successful at achieving your weight loss goal. Congratulations. But you don't fill out your bra anymore. What is that about?

Most women who undertake a significant weight loss through diet or through weight loss surgery are hoping to lose fat. That's the part of the body that we don't need so much. We don't want to lose a lot of muscle when we do a weight loss thing. But some parts of our body are mostly fat, and that would be our breasts, and weight loss may lead to a body change that isn't welcome. So what can we do about that?

Today, in the virtual Scope Studio, I'm talking with Dr. Cori Agarwal. She is a plastic surgeon who specializes in aesthetic and reconstructive surgery at the University of Utah, and she has an interest in helping women find the body that they're looking for.

So I have some questions about this, because this is a really interesting topic for people who have really undergone a basic transformation of their body, whether it was 30 or 50 pounds, or they lost baby weight and the baby and then they nursed and so their body isn't the same. After substantial weight loss, women may find their bodies change in ways that they hadn't anticipated. Can you talk about weight loss and how it affects breast structure?

Dr. Agarwal: I think that's a really overlooked conversation when people set out to lose weight. They're really focused on health and kind of the getting back to feeling more active. And sometimes it's a surprise when there's this negative effect on specifically the breasts.

The breasts, as you mentioned earlier, are made up of quite a bit of fatty tissue, and that really varies person to person. But I'd say most women, especially as we age, the breasts become more and more percentage of fat. So when you lose weight all over your body and you lose fatty weight, naturally some amount of that is going to come off of the breasts. And you don't always know until you're there. So, for some women, it's just a minor effect. And for some, it's completely deflated after the weight loss.

Dr. Jones: Oh, deflated. I mean, it's hard enough getting older and if you've had babies, but to have . . . even that word deflated, that would have me rushing to you to get some help.

Dr. Agarwal: Well, I was going to say the deflation, it's really important to think of it in two areas. There is the loss of volume, so the loss of this fat where you really just lose the size of your breast. And then there's the deflation, the sagging of the skin where the nipples kind of point down and everything stretches down.

And those two we really think of separately and independently. When we talk what options there are for rejuvenating and filling the breasts, we really think of the sagging and the loss of volume separately, because not every individual has as much sagging or as much loss of volume.

Dr. Jones: When you said there are really two parts to two different kinds of changes that happen with weight loss, there's sagging and then volume, what are you going to do? What are the procedures here that you're going to undertake with this woman?

Dr. Agarwal: There are really two main objectives. And one is to fill the volume to the size that was lost. And for some women, they want to be a little bit smaller than they were to start. Some want to be a little bit bigger. And to fill that volume back, to restore that deflated volume, the mainstay operation is a breast augmentation, and that's placing an implant in the breast usually behind the muscle to regain the volume.

However, if the skin has at the same time sagged, which it usually does, in the process, there needs to be a skin tightening procedure done at the same time. And that's called a mastopexy or breast lift.

Now, these can be done independently. Someone may just want the lift. They might like the size that they've ended up, but everything's just droopy. So we'll just do the breast lift. And then more commonly, we will offer and recommend a lift with an implant, because in most people, I think both of those processes are happening. That's something that's very individualized, but I think it's important to think of those two separately, the lift and the augmentation.

Dr. Jones: And so, rather than some people thinking they're just going to have a little incision somewhere and something is going to be slipped in and pumped up or something, you're really going to have to remove some skin and maybe lift the nipple.

Dr. Agarwal: Right. I think that's often a surprise for women because they think, "Well, this is just like a deflated balloon. I'm just going to fill up the balloon," but they haven't really noticed how far things have stretched. And we really have to have an honest conversation about what it will look like with just the implant, or if you really want or would recommend a lift along with that implant.

Dr. Jones: So what are the options for women who would choose breast surgery? Do you call it aesthetic or cosmetic, or in this case, is it really reconstructive and is it paid for by insurance?

Dr. Agarwal: That's a really important thing, and so many things are blurred in the world of plastic and reconstructive surgery. A lot of things that we do that are reconstructive really are also cosmetic, and there is a blurred line, especially when it comes to the breast.

So when we talk about the words cosmetic and reconstructive, what we're usually getting to is "Will insurance pay for it?" Because if insurance sees it as cosmetic, then even if we think it's really truly a reconstructive thing, building your body back, we have to call it cosmetic. And the sad truth is that for most breasts that have sagged or lost volume almost all the time will be considered cosmetic by insurance companies and is not covered.

Dr. Jones: Well, for women who part of their weight loss journey has been becoming really active, and now they have breasts that don't want to stay where they want to put them, that ends up getting in the way of their being the physically active person that they have to be if they're going to maintain their weight loss.

Dr. Agarwal: Right. And we do try to make those arguments to insurance, but I think that it's just outside the scope of what we can declare medically necessary for the breast. Breasts sag for so many reasons. Pretty much anyone who has gone through a pregnancy and nursed a baby, even just age, breasts just sag almost 100% of the time. And so I think that's just beyond what we can argue for insurance to cover.

Dr. Jones: Knowing that many people who lose weight gain it back again, is there any recommendation about waiting for weight to stabilize for a while before considering breast augmentation? I mean, we've all watched the successes and failures on "The Biggest Loser," and some people are back right where they started from within a year or two. So how do you counsel people in terms of when they should consider this reconstruction?

Dr. Agarwal: I think as a general rule of thumb after a lot of weight loss, we'd like people to maintain their weight for about six months. If it's just a quick diet that's severe and maybe they're going to bounce right back in a couple of months . . . but by six months of sustained weight loss, most people are pretty steady in their weight. So that's the general recommendation, but of course, it's very individualized.

Dr. Jones: Right. And can this surgery be part of a larger surgery? So you certainly know people who have maybe had bariatric surgery and they lost 150 pounds, and now they have sagging not just in their breasts, but throughout skin, all over their body, which becomes a significant issue in just terms of staying healthy. Can you do redundant skin reduction at the same time that you do a breast surgery, or are these staged at different times?

Dr. Agarwal: I think both are true for each individual. When we're thinking about doing reduction of skin, tightening of skin after a lot of weight loss, safety is the main priority. We want to limit the amount of time under anesthesia for any individuals. So if they came in and said, "I want my breasts and my belly and my thighs and my back," we really have to slow it down and say, "Okay, what's the most important thing here? Can we combine it with something else?"

We try to limit the surgery time somewhere between three and six hours. And so we can do sometimes breast work with something else, but depending on what other areas are the priorities, it's very common to stage this.

But that's the conversation we have after we get to know the patient and see how healthy they are, how prepared they are for a long recovery. So it can go both ways.

Dr. Jones: So when you say how healthy they are and how emotionally prepared, it's hard when you have just a few minutes to get to know someone. And I know that sometimes before people undergo bariatric surgery, they might actually see a behavioral psychologist. But how do you get to know people to know that this is the right thing for them to do and they're not just seeking something that's really unobtainable? How do you set realistic expectations about what they're hoping for?

Dr. Agarwal: This is really important. We spend a lot of time . . . I'd say the first visit is usually about an hour. And during that time, a portion of it is talking about the surgery and evaluating them. But a big part of it is talking about how they've gotten to that point, how they feel, what their expectations are, and then their social support. I think social support is critical when you talk about getting through a big surgery like that. And so we'll make sure that they've really thought through who needs to help them, someone to help with the children, someone to help with themselves and their work. So that first visit, we do a fair amount of that really trying to get to know someone.

And you're right, it's only one visit, but usually we have another one or two visits after that before surgery and really get to these critical questions of whether they've thought this through and have the support on the other side. Some will have to really set realistic expectations, that you will not have a 20-year-old body after this, but you will have this and you won't have that. So we try to be really realistic and not try to sugarcoat it or make it seem better or easier than it will be.

Dr. Jones: Right. Well, I would think that most people having gone through . . . particularly if it was significant weight loss, they've been with this body for a while and they know what they're looking for, and I bet you they're mostly pretty realistic. They're not coming in with perfect breasts hoping for more perfect breasts.

Dr. Agarwal: I wish that was the case in everyone. I think there are certainly a lot of women who are exactly in that category, but there are a lot of people who still . . . maybe it's a lot of the TV shows out there, but there is an idea that there's some magic that happens and some Photoshopping. I do think we have to ground them sometimes if maybe what they've been seeing isn't realistic, because . . .

Dr. Jones: I've seen some of those YouTube videos, the befores and the afters, and I look at the afters and say, "How can she have lost 150 pounds and have breasts and legs that look like that? Is that real?"

Dr. Agarwal: Exactly. So you have to take a lot of it with a grain of salt, and so that's the job. I think that that's the consultation. You're not going to know that before really meeting with your surgeon and understanding what can be achieved.

Dr. Jones: I want to thank you because I hadn't really thought about this one. Certainly I've had patients over the years who were thinking about bariatric surgery, and I didn't really take them through all the steps that this will happen when you get there. You will get there, but then this may happen. It may not. So I want to thank you for giving us some insight.

And for women who've taken the big steps to make a big positive change in their body through weight loss, there are sometimes still steps to take to feel like yourself again. You're not alone and there are options and procedures that can help.

I want to thank you, Dr. Agarwal, for joining us. And thanks for everyone who's listening on The Scope.

When the father of an iconic female pop star went public with the diagnosis of his breast cancer, it was clear that we don't think about our boys and men and this disease very often.

This is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Health, and this is "The Seven Domains of Women's Health" and a little bit of men's health on The Scope.

All humans have breast tissue as a developing fetus. Baby boys and especially baby girls often have breast tissue that can be felt under the nipple shortly after they are born that has been stimulated by the hormones of pregnancy. Boys in early adolescents may grow more breast tissue as their early hormones from the testes stimulate the breast cells until testosterone rises enough to suppress the effect of estrogen. And then we mostly forget about it.

Breast cancer in men is the same type of breast cancer as in women, cancer of the breast ducts called ductal cancer and cancer of the breast lobules is called lobular cancer. Breast cancer in men is uncommon and makes up only about 1% of all breast cancers. Men who do develop breast cancer do so at a later stage in life than women, with an average age of about 72. The rate of breast cancer in the U.S. is about 1.9 white men out of 100,000, and in African-American men it's about 2.7 in 100,000. And the lifetime risk of a man getting breast cancer is about 1 in 800.

So it's not so common, but the incidence of breast cancer in men has been slowly rising over the past 40 years. At least in one study of breast cancer of men in Britain, the exact reason for the rise isn't known, but the risk factors for men include anything that increases estrogen, obesity, liver disease, heavy alcohol use, and diseases where men make less testosterone. Of course, family history and genetics play a role. About one in five men with breast cancer have a close family member with breast cancer. Usually that's a woman.

Now, when a woman develops breast cancer, we think about her family history, the other women who are close to her genetically, mothers and sisters and daughters, and then grandmothers and maternal aunts. If there seems to be a family pattern, we often suggest genetic testing for women. If the woman with breast cancer is positive for one of the gene mutations associated with breast cancer, like BRCA1 and 2 mutations, we offer counseling to the family and suggest that the close women relatives be tested.

But we should be talking about whether the men should be tested as well. If a man develops breast cancer, we should offer him testing. If a man has a mutation in the BRCA1 gene, the chance of getting breast cancer is 6 in 100. And if he has a BRCA2 mutation, it's 1 in 100.

The signs of breast cancer in men are the same as in women -- a lump near the nipple, dimpling of the skin near the nipple, or nipple discharge or blood from the nipple. So families with genetic risk for breast cancer should consider testing and counseling the men in the family. There are no recommended screening tests for asymptomatic men, men without any signs or symptoms. And mostly, it is important for men who notice changes in their nipple or the tissue around the nipple, they should bring it to the attention of their clinician. Early detection is just as important for treatment in men as it is in women because who cares about men's health? We do.

And thanks for joining us on "The Seven Domains of Women's Health" because we love our men.

Dr. Jones: With respect to breast cancer risk, smaller breasts doesn't mean less. All breast sizes need mammograms. Women with different size breasts have ideas that breast size may affect the risk of breast cancer and the need for screening mammograms.

Well, breasts are different, and here to unravel some of the issues for us is Dr. Helen Mrose, a specialist in breast imaging and a radiologist here at the University of Utah. Welcome to The Scope studio, Dr. Mrose.

Dr. Mrose: Thank you for having me.

Dr. Jones: Okay, so when it comes to breast cancer risk, does size matter?

Dr. Mrose: Actually, no.

Dr. Jones: Okay.

Dr. Mrose: Size does not matter. People with small breasts and large breasts get breast cancer in equal frequencies or so we think.

Dr. Jones: Right.

Dr. Mrose: There are many things that matter having to do with breasts, including whether the breasts are dense or not, but that doesn't necessarily have a lot to do with breast size.

Dr. Jones: Oh, good.

Dr. Mrose: That's something we inherit.

Dr. Jones: Or we grow postmenopausal women, it turns out who gain weight after menopause, which happens. It's not uncommon for postmenopausal women, it's breasts that get larger, or for women who go on a diet and lose a lot of weight for their breasts to get smaller.

Dr. Mrose: Correct.

Dr. Jones: So there's some changes that go through in a woman's life.

Dr. Mrose: That's absolutely true. The breasts are composed of basically just two things -- fat and what's called fibroglandular tissue. And it's the fibroglandular tissue that is what's called dense. And for some reason, some people have very little fiber glandular tissue and some people have lots of it. And that has been found to be associated with breast cancer risk, but you're born with that or you develop when your breasts developed. You have a certain amount of that fibroglandular tissue, and you're absolutely right when the breasts get bigger, which they tend to do when people get older and they gain weight, they get more fat. But that's not known to be associated with breast cancer risk specifically.

Dr. Jones: So when it comes to early detection of breast cancer, does size matter in terms of how you do the mammogram or whether the mammogram is good at picking up cancers?

Dr. Mrose: Hopefully, not.

Dr. Jones: Oh, that's what I want to hear. Doesn't matter.

Dr. Mrose: Of course, when someone's breasts are very small, or if they're very large, it's more challenging for the technologist. We do have different size compression paddles to accommodate different sizes. And one thing that really matters is the skill of the technologist who's performing this study. And many people think it maybe it doesn't matter. It's just like snapping a chest X-ray. But doing a mammogram is quite an art that technologists who perform this are specially trained, they have to go through quite a bit different training than a regular X-ray technologist. And they have to keep up a certain number that they do and take exams. And they need to be supervised by people like me, who are the people who are watching the quality of their work and making sure that they're doing an adequate job. It's difficult to include all the breast tissue on the mammogram.

Dr. Jones: Well, here in the studio today, we have breasts of different sizes. And we won't use names, of course, because that would be HIPAA. But clearly, people with larger breasts to get all of the breast into it means you have to squeeze hard and squeeze all of it. So women who are large breasted tend to think that their mammograms hurt more, and people who are small breasted think that their mammograms hurt more. And I'd say hurt is all up to the person in this not up to the breast size. What do you think about that?

Dr. Mrose: That is true. It can be very painful or not painful at all. And a lot of it has to do with expectations, I think. A lot of it has to do with the skill of the person who's performing the examination. Because I think everyone having a mammogram feels some kind of stress because it's a test for cancer. It's one of the only tests that we do that's the only question is, is there cancer there? So of course, that's stressful.

But some people do not feel much discomfort. And it only lasts for a few seconds. The compression, which is what you're talking about that can be uncomfortable is really important for a number of reasons. The thinner we can get the breast tissue, the less radiation is necessary to produce the image. And this is really important, but also the thinner the tissue, the more detail we get by a lot, and the more things are spread apart, which is very important for our detecting things.

But when you ask a question about the size of the breast, when people have fatty breasts, which you can't tell by how they look or feel or even the size, they are easier to read, because we're looking for white things on the black background. Fat is black. When people have dense breasts, they have a lot of white background. And so we're looking for white things that might be hiding in amongst other white tissue. And therefore that compression is so important. We're spreading things apart so we can see those little white things.

Dr. Jones: Well, I tell women who, particularly women who've had labor, that it's nothing like a contraction. And if they can count to eight slowly, it's not going to last longer than eight seconds. Usually, by the time they really start cranking it down, and maybe we can all handle something, just a slow count to eight would get you through it.

Dr. Mrose: We can. And breast cancer is much more painful than having a mammogram.

Dr. Jones: Right.

Dr. Mrose: So I do encourage people, if we can find something early, or even in the pre-cancer stage, that that is a lot less painful.

Dr. Jones: That's a good way to put it.

Dr. Mrose: Yeah.

Dr. Jones: You know, we've heard a lot more about digital mammography and mammography, this and mammography that. I've told my patients it was always important to go to a center that had their radiologists on-site looking and supervising and did a lot of mammography. But are there any particular kinds of mammograms that are important?

Dr. Mrose: The most modern technology that we have is called 3D mammography or tomosynthesis. And this is a digital mammogram, but rather than just producing a 2D image, there are several slices, one-millimeter slices of tissue. So that we can page through the tissue like on a CAT scan or an MRI and see much, much more detail. It's actually incredible how much more detail we get with a 3D or tomosynthesis mammogram than with regular 2D.

Dr. Jones: So the patient isn't actually turning around in a 3D, you know . . .

Dr. Mrose: No.

Dr. Jones: . . . scanner. It's just the way that computer takes the image. That process of for the woman of having the image taken it's the same, but it's the way that computer takes the data.

Dr. Mrose: The machine is very similar, except the tube head where the X-ray is coming from actually moves. The woman doesn't move. She's just in compression, but the tube is making an arc so that it's taking images at different angles, just like in a CAT scan. That then can be synthesized with the computer to make the one-millimeter slices.

Dr. Jones: So do insurances pay for 3D mammograms?

Dr. Mrose: Absolutely, they do.

Dr. Jones: And is that what we normally do here at the U at the University of Utah?

Dr. Mrose: Most of our sites at the University of Utah are 3D. Certainly the Huntsman is all 3D.

Dr. Jones: That's great.

Dr. Mrose: Everyone is a specialist in reading mammograms, and that's something that is also important.

Dr. Jones: Well, so when do you recommend starting mammograms?

Dr. Mrose: I recommend for someone who's that average risk. What I mean by that is someone without a strong family history of breast cancer or known gene mutation that's associated with breast cancer. I recommend starting at age 40, and doing it yearly. And I know there's a lot of controversy about that. But the reality is all women are at risk for breast cancer. The majority of cancers that we find are on women without any known strong risk factor. And this means that having a discussion with your doctor about whether you should have a mammogram at 40, or how often is almost meaningless because everyone is at risk.

Dr. Jones: Think that's an important point because many women say, "Oh, I don't need to be screened because there's no breast cancer in my family." And I say only 5% of breast cancers are familial.

Dr. Mrose: Right.

Dr. Jones: The rest are still gene, you know, mutations, but only 5% of breast cancers are familial. And the rest is a DNA mutation that's made a cancer, but everybody needs to be screened. Well, so when do you recommend stopping screening?

Dr. Mrose: Well, since other than being female, which is the strongest risk factor for breast cancer, age is the strongest factor after that. When you hear the statistic that one in eight women will get breast cancer, that is actually not correct. It's one in eight women who reach 80 will get breast cancer, and that's very different. So what is important is if a woman is healthy, if she has a life expectancy of at least 5 to 10 years, I would say she should continue mammograms indefinitely.

And I have a 94-year-old mother who's healthy, plays pickleball every day. And I think she should have mammogram not because if she had cancer, we would do something aggressive. But I would have them take it out, which is a very straightforward procedure under local anesthetic, which would keep her from going on to develop something that would be very painful.

Dr. Jones: Well, I consider it a chance to go out, get out of the house and go out for lunch. So I think having a mammogram is a reason to meet with your friends and you know, have somebody take you or go with you and party a little.

Dr. Mrose: Many women do that. I had a group of friends from college who all came together in the . . . they called it the mammo van, and they would all come together and then we will all go out to lunch.

Dr. Jones: Well, although some recommendations about when to start and when to stop are still . . . you may hear different things. All women do need to be screened no matter what size they are. And Dr. Mrose, thanks for joining us with this and thanks for all of you listening on The Scope.

Are young women getting more breast cancer? This is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Health. And this is "The Seven Domains of Women's Health" on The Scope.

For women with an extended web of family and friends, it seems as if we are hearing about more young women getting breast cancer. Is that about our social networks being more easily accessed? Facebook, our news links, are friends' friends becoming our friends? Is it about early and more accurate screening picking up more cancers? Is it in the water? Let's think about what we know and what we think we know. Well, let's start off with who do we think of as young?

Well, young, of course, is anyone who hasn't lived as long as you have. However, in the world of breast cancer, young women are under 40. Although breast cancer in young women is uncommon, it's the most common malignant tumor in young women, 15 to 39. The lifetime, well, not all your life but life up to 40, risk of getting breast cancer was 1 in 173 when it was reported in 2009. Now, that's compared to the whole lifetime risk. Risk of getting breast cancer at any time of your life before you die is about 1 in 8.

A report in 2013 in the "Journal of the American Medical Association" looked at the incidence of breast cancer as reported to the U.S. National Cancer Institute's Surveillance, Epidemiology and End Results database. That is a mouthful, but it's commonly known as the SEER database. Everything cancer that happens in the U.S.

This study looked at the incidence of all breast cancers from 1973 to 2009. They categorized breast cancer by age of the woman in whom it was detected and whether the cancer was local, meaning just in the breast, regional, in the breast lymph nodes or chest wall, or distant disease in the bones, brain, or lungs. They found that the incidence of distant disease in older women over 40 was not increasing, but that the incidence of breast cancer that had spread far from the breast was increasing in women 25 to 39. This database is so large that it can look at rare cancers, women who live in cities and in the country, women who are black, white or Hispanic. This increase in young women was found in black, white, and Hispanic women and urban and rural women.

Now, the increase was statistically large but not numerically large. And this is a very important difference to me and my listeners. The rate of advanced breast cancer in young women almost doubled, which sounds like a huge increase. But in absolute numbers, it went from 1.53 per 100,000 women per year in 1976 to 2.9 per 100,000 women per year. An absolute increase of a little over 1 per 100,000 women per year over the 36-year interval.

Another finding was that breast cancers that were estrogen-dependent had increased more than those that weren't. It's important because estrogen-dependent cancers are more amenable to treatment. And that's really critical for all women, but particularly, for young women with kids.

So getting back to the beginning. Why are there more breast cancers among young women? Why do we hear about it more? Could it be their ability to see distant cancers is increasingly better since 1973? So that's why we might be seeing more? Well, maybe but the authors say there isn't enough to explain all the increase. They didn't mention other factors, but we do know that obesity increases the risk of breast cancer in women of all ages. And obesity in young women has increased dramatically over the last 40 years.

We worry that there are environmental estrogens that may increase the risk of breast cancers. We know there are more synthetic chemicals that fetuses are exposed to in pregnancy and change the way that breast cells see estrogens or chemicals that adolescents are exposed to as the breast is developing. We also know that we are much more connected to people we barely know through social media and other media. So we hear much more about young women with breast cancer.

So, all in all, it seems as if breast cancer in young women is increasing. So what do we do about it? Well, you could turn off your social media and your contacts with your friends and family so you don't hear about it. But that isn't the way of women who are connected by the Woman Wide Web. We can support research into the role of chemicals in our environment, our water, our cosmetics and our home that might increase the breast cancer risk or make breast cancer grow and spread faster. We can be personally aware of our breast anatomy, promote breast self-awareness, and bring any new changes in our breast to the attention of our clinicians. And we can try to remember numbers and put this small increase in breast cancers in young women in perspective. And thanks for joining us on The Scope.

Dr. Jones: Do women with breast implants have a higher risk of cancer? What cancer? What's the risk and what should we know?

Announcer: Covering all aspects of women's health, this is The Seven Domains of Women's Health with Dr. Kirtly Jones on The Scope.

Dr. Jones: There are about 300,000 breast implant surgeries performed every year in the U.S. Now, there are a number of reasons for breast implant surgery, but all people requesting breast implant surgery have concerns about risks and side effects. There's a new concern about a very rare cancer that might be more common in women with breast implants.

And today in The Scope studio, we're talking with Dr. Jay Agarwal, who is chief of Plastic Surgery at the University of Utah. He's a plastic surgeon at the Huntsman Cancer Institute, who specializes in breast reconstructive surgery, and he's going to help us think about this risk.

Welcome back to The Scope, Dr. Agarwal.

Dr. Agarwal: Thank you. Thank you for having me.

Dr. Jones: So what did the FDA identify as a possible association between breast implants and a rare non-breast cancer?

Dr. Agarwal: Over the past decade and a half, the FDA, the medical societies, and doctors in general have been paying very close attention to the outcomes of their patients that have had breast implants placed. And so, over the past number of years, we found that there is a very small but significant incidence of a rare lymphoma, and it appears that it's associated with a specific type of breast implant, whether they're placed for reconstructive purposes or cosmetic reasons. And that's ALCL, an anaplastic large cell lymphoma.

Dr. Jones: That's a new one to me.

Dr. Agarwal: Yeah. Most people haven't heard it.

Dr. Jones: Right. Very rare.

Dr. Agarwal: And it's not a breast cancer as we think of breast cancers. It is a lymphoma. It's typically found in the capsule, the scar tissue that surrounds a breast implant. But again, I want to emphasize that it's exceedingly rare.

Dr. Jones: If there's an increased risk, what kind of numbers are we talking about?

Dr. Agarwal: We're talking about really low risk. It appears that patients with breast implants have about a one in 3,800 to one in 30,000 risk of developing this type of lymphoma. To put that in a broader context, you can think that the average woman in the United States, one in eight women will develop breast cancer.

Dr. Jones: In their lifetime, yeah.

Dr. Agarwal: In their lifetime. So this is orders of magnitude lower than that risk.

Dr. Jones: So it's very small or . . . this is where I put it in the teensy when I . . . this is my teensy risk.

Dr. Agarwal: That's correct.

Dr. Jones: However, it's a scary thing because many women who are having implants are maybe not doing it for cosmetic purposes but for reconstructive purposes, and they already have cancer on their brain and their heart. What kinds of breast implants are the most likely?

Dr. Agarwal: So what we've seen, first of all, there have been about 400 to 500 cases of this ALCL reported to the FDA. And after looking back at those patients and the types of implant they've had, it appears that the highest association is with textured breast implants.

Dr. Jones: So tell me about that. I don't get textured. Is textured meaning its outside is kind of rough, or what do you mean by textured?

Dr. Agarwal: That's correct. So breast implants come in a variety of styles. The first you may know is saline-filled implants or silicone-filled implants. And then another characteristic can be whether they have a smooth outer surface or a textured outer surface.

We started using textured implants because there was a thought that maybe it decreased the amount of scar tissue that formed around the implant or what we call capsular contracture. Sometimes we use implants that are slightly shaped, and the texturing helps prevent the implant from turning. But the association with the ALCL is the highest with the ones that have a texture on the outer surface.

Dr. Jones: Well, that has some biological possibility. I mean, it could cause a different kind of reaction than a smooth, slippery one.

Dr. Agarwal: It could. It's possible that the texturing creates more inflammation or an area for bacteria to reside and cause an inflammatory response.

Dr. Jones: You mentioned that it's in the capsule or the area around the breast implant. How does this present? Because quite frankly, when we think about lymph cancer, I think about lymph nodes, I think about armpits, neck nodes. I wouldn't think of looking at the breast itself. So how might it present if I were an OB/GYN or a clinician? What am I looking at?

Dr. Agarwal: Right. So patients who've had breast implants can present to their physician, OB/GYN, general family physician, or their plastic surgeon with a variety of different complaints. The breast is swollen, it's become more painful, or they feel a mass. The most common presentation is fluid around the implant. And about 86 percent to 90 percent of patients who've had this ALCL presented with what we call an effusion or a seroma around the implant.

Dr. Jones: Was it years after their implant or . . . it must have been years because cancer doesn't happen in a day.

Dr. Agarwal: Right. So the average time to presentation of the 400 to 500 patients that have had this has been 8 to 10 years after the breast implant has gone in.

Dr. Jones: Right. So if it's 400 in the U.S., that means the vast majority of plastic surgeons, OB/GYNs, primary care docs, nurse practitioners have never seen this, have never heard of it. But if a patient comes with a new complaint some years after the breast implant should be pretty stable, they should know enough to say, "That's not normal."

Dr. Agarwal: That's correct. Again, to put it in a little bit of context, as you mentioned in your opening, there are about 300,000 to 500,000 breast implants that are placed annually in the United States. It's believed that worldwide there are about 35 million women who have textured implants, and it's believed worldwide about 1.5 million implants are placed annually.

So, again, small numbers, but any OB/GYN, family physician, plastic surgeon should be made aware of this, because as we're learning more about it and as we're observing our patients more closely after they've had implants placed, we're identifying more cases of this. And while the number is small, we don't know where it will end up at.

Dr. Jones: Right. Well, when we're talking about breast cancer, even a very rare one, people think about this being lethal. So, when this presents, is this usually a cancer that's spread already? Do most people die from this cancer? What happens when people find this cancer?

Dr. Agarwal: Most of the time with ALCL that's associated with breast implants, the cancer resides locally in the tissues around the implant. And for most of the cases, removal of the implant and removal of the capsule, the scar tissue around the implant can cure the patient of the lymphoma. In rare instances, the lymphoma can spread to the lymph nodes or elsewhere, but the most common presentation is a local one.

Dr. Jones: Well, that's actually great news for a rare cancer, for it to be actually mostly curable with the surgery, just remove the implant and capsule. To me, as a provider and as a woman, that's very reassuring to me.

Dr. Agarwal: Yes. Nobody wants to have an increased risk of anything if they're having a medical device placed. The good news is (a) it's very rare, and if caught within an early period of time, it can be cured by removing the implant and the capsule. If there's something good about it, I'd say.

Dr. Jones: That's right. I think that's good news about bad news.

Dr. Agarwal: Right. I will say that at the University of Utah and Huntsman Cancer Hospital, we have placed a moratorium on textured breast implants. We no longer place any textured implant until the medical community and the FDA learn more about this ALCL, and until we feel confident or have some better understanding of what the true association, if there's really a cause and effect association.

I think you want to ask all the right questions as a patient. What type of implant am I having placed? What are the risks of the surgery? What are the risks of the implant?

From the physician side, it's important to do a full physical exam when your patient comes in for their annual visit. That includes a full breast exam, particularly in patients who have had breast implants. If a patient notices anything suspicious or a change in the shape, size, or feel of their breast, they should bring it to the attention of their physician. And if an OB/GYN or a family practice doc has concerns, they should then have the plastic surgeon involved.

The FDA at this point recommends that either an ultrasound or an MRI can be done as a screening tool. Anyone who has symptoms should go directly to MRI. Anyone who has an implant placed, particularly a textured implant, should have a screening MRI after five or six years after the implant was placed.

Dr. Jones: Well, for many women who are making the choice about breast implants, only they will be able to balance the risks and benefits in their own bodies. But we try to give them the best information that we have and help support them with their decision. Thanks, Dr. Agarwal, and thanks for joining us on The Scope.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there's a pretty good chance you'll find what you want to know. Check it out at thescoperadio.com.

Recently the Food and Drug Administration (FDA) has identified a possible association between textured breast implants and development of a rare form of cancer called anaplastic large cell lymphoma (ALCL).

The majority of the data suggests the cancer risk is associated with breast implants that have textured surfaces rather than those with smooth surfaces. The risk is low and thus far only a small percentage of patients with textured implants have been found to have ALC in the United States. Nevertheless, out of an abundance of caution the FDA has recalled a specific brand of textured implants.

The Division of Plastic Surgery at U of U Health has stopped using all brands of textured implants in light of the recent concern of developing ALCL. Please note that the recall of these implants does not mean that the implants need to be removed. If you have concerns or questions regarding the recall please refer to the FDA website or speak with your doctor.

For More Information About the FDA’s Ongoing Status on Breast Implants and ALCL

Dr. Jones: New news and old news about the risk of breast cancer and hormonal birth control. Get ready for some really very big and very small numbers. This is Dr. Kirtly Jones from Obstetrics and Gynecology at University Health and this is The Scope.

Announcer: Covering all aspects of women's health. This is The Seven Domains of Women's Health with Dr. Kirtly Jones on The Scope.

Dr. Jones: Today we're going to talk about hormonal birth control and the risk of breast cancer. Primarily, we'll talk about birth control pills, but we'll also talk about hormonal patches, shots, implants, and IUDs. There are now 50 years of data on the topic of hormonal birth control pills and the risk of breast cancer. Largely, the studies have suggested that there's no significant increased risk of breast cancer in birth control pill users except maybe in women who used pills starting early in their teens, used them for a long time, and use them into their 40s. Recently, a study from Denmark looked at 1.8 million women between the ages of 15 to 49 who had used hormonal contraception between 1995 and 2012. They were using contraceptive methods that are commonly prescribed today. Because Denmark has a health system that can follow everyone and link diagnosis with prescriptions and health outcomes, they can really do big studies.

So what did they find? First, the extra risk of breast cancer in women of this age group who took hormonal birth control of any type during this time period was 13 extra breast cancers per 100,000 women per year. That's a very small number, 13, out of a pretty big number, 100,000. That is, for every 100,000 women using hormonal birth control, there are 68 cases of breast cancer annually compared to 55 cases a year among non-users. Another way to crunch these numbers is to say there was one extra breast cancer for every 7,690 women using hormonal contraception.

Of course, the details are a little more interesting. For the users of hormonal patches, the extra breast cancers were 5 per 100,000, but it ranged from 1 fewer and 11 more, and essentially it wasn't different from women not using hormonal birth control. Maybe there are just weren't as many women taking it. It's not clear, because the hormonal patch is kind of like the hormonal pill.

For women using vaginal rings, there were two fewer breast cancers. But the statistical range was 32 fewer to 28 more. So there wasn't any increased risk in this group.

The same kinds of numbers were seen for women using contraceptive implants or injections. There were about 5 to 10 fewer breast cancers, but the ranges were so large that there really wasn't an increase or a decrease.

Hormonal IUD users had about the same increase as pill users with about 16 extra breast cancers per 100,000 women. Importantly, and listen to this, the risk for women under 35 years of age was 2 extra breast cancers per 100,000 women per year, a really small number. Young women had a lower risk of breast cancer on hormonal contraception than older women. And women who had used hormonal contraception for a long time, meaning 10 years or more, had a slightly larger absolute risk than women who only used it a short time.

So what do we do with these numbers? First, don't panic. Every time there's bad news about contraception, even if it's barely bad, women stop their contraception and the unplanned pregnancy rate and abortion rate goes up. Now there, you're really taking some risks. It is really hard to know how to counsel women about a risk that is one extra per 7,960 women. Those are numbers that people don't really understand very well. Also, people really don't like numbers like 7,960. They like 10 or 1,000.

So I consider a significant risk is 1 extra in 10. A low risk is 1 extra in 100. A very low risk is 1 extra in 1,000, and an extremely low risk is 1 extra per 10,000, and that's really what we're talking about. The authors of this study admit that they didn't control for age of first period in these ladies, alcohol consumption, breastfeeding, and physical activity. All of these activities increase or decrease the risk of breast cancer by a little. Breastfeeding decreases the risk of breast cancer, and certainly women who breastfeed are less likely to use hormonal birth control. So that could be part of why there was a slight increase in hormonal birth control users.

Now, there's something called biological plausibility. In population studies, they'd find a correlation of one thing with another. Let's pick alcohol. People who drink alcohol moderately live longer. People who drink alcohol a lot don't live so long. Now, is it the alcohol that makes you live longer? Or is it the people who drink alcohol have more fun, have more friends, and having friends makes you live longer? So this is a biological plausibility issue.

Is there a biological reason that hormonal contraception might very slightly increase the risk of breast cancer? Over the past 20 years, researchers have been more interested in the progestin component of the hormonal contraception and menopausal hormone replacement therapy. We always thought that the risk for breast cancer was all about estrogen, but progestin, that other hormone in hormone replacement or in hormonal birth control, seems to add a little risk as well. So there's a possible biological reason for this very small increase in breast cancer in hormonal contraception users.

The authors of this study also suggest that women don't panic, but they didn't exactly say that. They mentioned that hormonal birth control pills have substantial health benefits. Birth control pills substantially decrease the risk of uterine and ovarian cancer and possibly colon cancer. In fact, women who have the BRCA gene for breast and ovarian cancer have been suggested to take birth control pills because even if the risk of breast cancer is slightly greater, the risk of ovarian cancer, a cancer that's hard to detect and hard to treat, is so much less on birth control pills.

So what should you do? We all know that hormonal contraception comes with risks and benefits. For the vast majority of us, the ability to control when and how often we have children is a fundamental factor in our ability to manage our lives. Many women use hormonal birth control, such as hormonal IUDs, to manage flooding periods and pain that debilitates them every month.

If these recent findings are a major concern for you, talk to your clinician about the risks and benefits for you personally. Not you in 100,000 women. Put things in your own personal perspective. There are options for us, probably more than you know, and thank you for joining us on The Scope.

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Interviewer: It can be a little confusing sometimes because there are actually two different types of mammograms. There's a diagnostic mammogram and then there's a screening mammogram. We're going to try to figure out the difference between the two of them so you can decide which one it is you might need.

Announcer: Health tips, medicals news, research and more for a happier, healthier life. From University of Utah Health Sciences, this is The Scope.

Interviewer: Dr. Anna McGow is a radiologist at University of Utah Health. Let's break down the difference between the two different types of mammograms. First of all, what is a screening mammogram and who needs that?

Dr. McGow: Right, yeah. Thank you very much. So a screening mammogram, those are performed in women generally who are over the age of 40, 40 and above, who have no breast symptoms. So they do not have symptoms such as focal breast pain, they do not feel a lump, they have no breast skin changes, no nipple discharge, no skin retraction, no lumps in the armpits. Those particular types of symptoms would require a diagnostic mammogram and/or a breast ultrasound.

Interviewer: Okay. So just to be clear, you're going in for a screening mammogram if you have absolutely no symptoms of breast cancer, and that's the one that you just do every year, just so you can get a picture and see what's going on inside.

Dr. McGow: That's right, yeah, just to screen for breast cancer.

Interviewer: And if you have symptoms, then you're going to want to make sure that you're getting a diagnostic mammogram. What's the difference?

Dr. McGow: Yeah, no, that's a great question. So we have women who come in all the time just for a screening mammogram when in fact they should be getting a diagnostic mammogram. To get a diagnostic mammogram, again, a woman has breast symptoms that need to be evaluated and they need additional evaluation beyond the four standard pictures that we usually do for a screening mammogram.

The diagnostic mammogram and/or ultrasound requires a physician order, so from your regular family doctor or other physician. And when a woman comes in for the diagnostic evaluation, a radiologist physician, such as myself, needs to be present for that evaluation. As opposed to a screening mammogram, where a woman would just come in and get the standard four pictures and leave.

Interviewer: And that does not require a physician's order?

Dr. McGow: Those usually do not in Utah.

Interviewer: Yeah. That's just you go into your doctor and you'd say, "It's time for my regular screening mammogram."

Dr. McGow: Yes.

Interviewer: Got you. So it's important to know the difference. You say that there are times that a woman with symptoms will come in and will have been scheduled for a screening mammogram. How can they make sure that that doesn't happen?

Dr. McGow: So the first thing that they need to do is realize that they have a symptom and then call their regular physician's office and tell them about the symptom and request an order to be placed for a diagnostic mammogram.

Interviewer: Okay. So they might not even need to go in and visit with the doctor. They might have to.

Dr. McGow: Exactly. Usually, their physician will like to see them to evaluate the symptom, of course. But if not, if it's something urgent that the woman is very concerned about, they may go ahead and schedule that diagnostic mammogram evaluation with us first.

Interviewer: Okay. I can see how it can get a little bit confusing there at times.

Dr. McGow: Yes, yes. For sure. And so we just want to avoid women getting scheduled for screening mammograms when in fact they have symptoms and then being sent away if a radiologist physician is not there to evaluate them properly.

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Dr. Jones: You got your screening mammogram report and it said that you had dense breast tissue. What does that mean? Should you be worried? This is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Health Care, and this is The Scope.

Announcer: Covering all aspects of women's' health. This is The 7 Domains of Health with Dr. Kirtly Jones on The Scope.

Dr. Jones: First, a little about breasts. Breasts are mainly four kinds of tissue. There are the breast lobules, which is the part that makes the milk that is pretty quiet unless you're pregnant or breastfeeding. There are the breast ducts, which carry the milk to the nipple. There is the fibrous tissue around those other tissues that keep them from bumping into each other. And there is fat.

The difference between large breasts and small breasts is the amount of fat in the breast. In young, premenopausal women, hormones keep the lobules and the ducts pretty active and the ups and downs of the hormones can increase the fibrous tissue. Weight gain can increase the fat, and weight loss can decrease the fat in the breast.

Of course there's also skin on the top of the breast, and the nipples and their blood vessels, and lymph glands, but they don't really count in the mammogram business. With the traditional mammogram, x-rays go easily through fat tissue but don't go through fibrous tissue very well, and don't go through cancer very well. So fibrous tissue and ductal tissue looks white on a mammogram, and so does cancer. When a woman is young, under 50, or premenopausal, the breasts are more dense according to the mammogram. When you get older, the breasts become mostly fat and are easy to see through.

When a breast is easy to see through, it's easier to detect cancers. When the breast is dense, it's harder to see the little cancers. Now, dense breast tissue is common. About two-thirds of premenopausal women have dense breasts, and about a quarter of postmenopausal women. Put the two together, and about 40% of women have dense breasts. Postmenopausal women on hormone replacement therapy tend to have denser breasts.

When my patients were worried about the term dense breasts, I just told them that they had youthful breasts. Which is always nice to hear, but it made it harder for mammograms to see through the entire breast.

So what are you supposed to do? First of all, the letter you received about the results of your mammogram is often not understandable. In fact, a recent letter to the journal of the American Medical Association noted that letters about dense breasts were written on average at the 11th grade reading level. Of course our Scope Radio listeners, wouldn't have any problem with that. But many people read much more below that level.

On top of that, about 24 states have legislated the wording of dense breast notifications. Yup. That's what the legislation is called, dense breast notifications. And we know how well the government explains things for those of you who do your own taxes. So if your report says you have dense breasts, it doesn't mean that you have cancer. It probably also said that your mammogram was normal. Remember, if 40% of women have mammograms have dense breasts, then it's normal.

However, the wording is there and in many states it is legislated to be there so women can know that maybe their mammogram isn't as good a screening test as it could be. This is the time to talk to your clinician about your breast cancer risk and your worries, and there are several risk calculators out there on the web. Other Methods of Breast Cancer Screening

There are other methods of screening if you're at high risk. If there's a lump that you or your clinician noted, then an ultrasound might be useful. If you carry a breast cancer gene that puts you at risk, then an MRI might be recommended.

For all of us, though, the invention of digital mammography several years ago made mammograms much better at looking through dense breasts. So there's been less of a chance of missing something. And there are also some new techniques.

So if you got the letter saying that your breasts were dense, don't freak out. You are normal. If you're at high risk for breast cancer, talk with your doctor and maybe another imaging technique would be right for you. And you can check out the website areyoudense.org and that can explain a little, and you can celebrate the fact that you still have young breasts. At least on mammogram.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there’s a pretty good chance you’ll find what you want to know. Check it out at TheScopeRadio.com.

updated: January 10, 2019
originally published: May 19, 2016

Dr. Jones: Disfigured, mutilated. These are words that are the way some women feel after mastectomy, the extensive surgery for breast cancer. What can we offer women who have had this surgery, to help them recover their self-image?

Dr. Jones: About a quarter of a million women will be diagnosed with invasive breast cancer in the US this year. Some will choose a smaller operation, a lumpectomy, but many will choose a larger surgery in their hope for a cure. And the percent of women choosing mastectomy is increasing. Although we're grateful for the treatments that can cure breast cancer, mastectomy can leave a woman and her body image profoundly changed. The Scope's Seven Domains of Women's Health team is in the office. I've Dr. Agarwal, a breast reconstructive surgeon at the Huntsman Cancer Institute, and we're going to talk about breast reconstructive surgery. So, Dr. Agarwal, tell us a little about your training. How is it different from a breast cancer surgeon, the person who did the mastectomy?

Dr. Agarwal: Well, I'm a plastic and reconstructive surgeon so my role is to try and rebuild. After a patient undergoes a mastectomy by the breast cancer surgeon, I work with the patient to try and then rebuild the breast. And this can be really any part of the body. As a reconstructive surgeon, our goal is to try and restore form and function for a patient.

Dr. Jones: Can you do the reconstruction at the time of the mastectomy, or are there advantages of doing it immediately versus delayed?

Dr. Agarwal: You can do the reconstruction at the time. We often, in fact, start the reconstructive process on the same time, in the same operative setting as the mastectomy surgery. Sometimes, it's a staged operation in which the first stage is started at the time of mastectomy and then the subsequent stages occur in the future. And sometimes, you can complete the entire reconstruction all in one setting.

There are advantages and disadvantages to doing it all at once. Some patients like the idea of just having one operation or, at least, having one operation where the majority of the surgery is done. Some patients like waking up from the operating room with the start of a creation of a breast, rather than waking up with a flat chest. The downsides are it does add surgery time and does add recovery time to the operation, but, in general, we're starting to see an increase in the number of patients that are having reconstruction that is initiated at the time of mastectomy.

Dr. Jones: Right. So women actually use to think of reconstruction as something that came to them six months or a year later when they felt like they were cured of their cancer and they were really ready to go on with the next step of their life. But now I think women are expecting to walk out knowing that they're going to feel a little bit more like themselves.

Dr. Agarwal: I think that's true. I think, in the past, reconstructive surgery was often considered something that was not part of the cancer care process of a patient. And today, reconstructive surgery and the role of a reconstructive surgeon are really integral into the entire comprehensive care of a cancer patient.

Dr. Jones: Right. So what's changed with our new tissues, new materials?

Dr. Agarwal: The types of surgeries we do and the technologies that we have have improved. We don't quite have the 3D printing of a breast down yet, although we may get there in the near future. But the quality, the implants, the implant material, and the ability to use tissues from different parts of the body has really improved dramatically over the past 15 years.

Dr. Jones: So we're using some of the woman's own tissues for some of the breast, and some implants, or combinations?

Dr. Agarwal: Both scenarios. So patients can have implants only, their tissue only, or a combination of implant and their own tissue. And that sort of depends on their body, their choices, and what may be the best option. And that often requires a discussion with their surgeon.

Dr. Jones: Well, honestly, Dr. Agarwal, as a woman, my personal fear about mastectomy, with or without reconstructive surgery, would be that I would be asymmetrical, that I'd have one normal breast and one plastic breast, and I just wouldn't be balanced. And I feel that breast had betrayed me already, and I wouldn't want to have breast cancer in the other breast. So I might ask you as if I were your patient to just do them both, so make them, when we're done, they can both look the same and be the same. Are you getting more requests? Does this sound crazy?

Dr. Agarwal: This isn't crazy. In fact, we're getting an increasing number of requests for bilateral mastectomy and reconstructions. And it's a very personal choice, it's not a choice that every woman makes, and it's not an easy choice. I think there are a lot of factors that go into it. Fear is, by far, the biggest factor. Patients exactly like you said, patients are worried that they might develop cancer in their other breast, or they're always going to be nervous and can't sleep at night and so they want to be free of that fear. And that's a real consideration when we consider doing a bilateral mastectomy.

I will say, though, just like any surgery, you have to be prepared that the more surgery you do, the more recovery, the more potential for a problem. So think carefully, talk to your surgeon, talk to your family before you make these decisions.

Dr. Jones: Fears of cancer and fears of disfigurement may lead women to avoid mammograms or seeking medical help if a lump is noticed. There are many more options for women as they face the challenges of breast cancer, and challenging, and living after a breast cancer treatment. Dr. Agarwal, thanks for helping us and think about our options, and thank you for joining us on The Scope.

updated: June 17, 2021
originally published: October 22, 2015

Dr. Jones: When women have had breast cancer surgery, the major surgery such as a mastectomy, they are often looking forward to living their lives and getting their body back. What are the new steps and what are the things that we have here at the Huntsman that will really help them make this difficult decision? How do we make the decision, and who is the team involved?

We are in the office of Dr. Agarwal here at the Huntsman Hospital with a beautiful view out the back door of people living their lives. I want to talk about how women who have had mastectomies make the decision to live their lives going forward as they make the transition from a cancer victim to a cancer survivor. We're talking about breast reconstruction here with Dr. Agarwal, plastic surgeon and reconstructive surgeon here at the Huntsman Hospital.

Let's talk a little bit about women who request the bilateral mastectomy. Of course, there are women with BRCA mutations, mutations that increase their risk of cancer. They don't have cancer yet, but both of their breasts are going to be involved so that's pretty easy to understand. How about if a woman has breast cancer on one side and wants the other one done? Does insurance pay for that?

Dr. Agarwal: Not always. We're seeing an increased demand, if you will, in patients who want to have the contralateral breast removed. A lot of times, this is driven by fear of developing cancer in the other breast. Oftentimes, it's driven by the desire to have symmetry and it's not a guarantee that your insurance will pay for this. More and more, we're seeing that insurance wants to really focus on the breast that has cancer and may not always pay for removal and reconstruction of the other breast.

But any time a patient has these concerns or desires to have both breasts removed, it requires a good discussion with their doctors, their oncologists, their surgeons because while things like symmetry may be improved in some cases, there are also potential consequences to having your other breast removed. You lose sensation of an otherwise normal and healthy breast. Just like with any other surgeries, there is the risk of potential complications by adding more surgery time or more operations.

Dr. Jones: And if women are young enough that they might want to consider having children if they get past their diagnosis and are cured, then they couldn't breastfeed if they have bilateral reconstruction and that has to be discussed. There is so much on the Internet about the pros and cons, but are there other women that someone can talk to? Do you have support groups of women who have made decisions and how they worked through their decisions? How do women go about finding out more information?

Dr. Agarwal: There are definitely support groups here at the Huntsman Cancer Hospital. There are teams of patients who have offered their services to other patients because they've gone through this process in the past and they give the whole picture, the good and the bad of going through this process. Throughout the Salt Lake community, there are organizations that provide a lot of information to patients, including Susan Komen's Foundation. So there are definitely support groups. I think that it is a very personal decision in the end and I think that a frank conversation with your medical team and your family is important when finally making these types of decisions.

Dr. Jones: Let's talk briefly about nipple reconstruction. I've heard that you have an amazing tattoo artist here at the Huntsman who might be able to even tattoo a nipple or are you using other tissues for nipple reconstruction?

Dr. Agarwal: First of all, we do have a great tattoo artist here at the University of Utah and Huntsman Cancer Hospital, but there are different ways of reconstructing a nipple. We can actually use some of a patient's own tissue to create the nipple itself and then tattoo the areola around it. And another option is to purely use tattooing. Some of the tattoo artists can create 3D tattoos of a nipple, which looks amazing. They look like real nipples that have projection even though they're flat on the surface of the skin.

Dr. Jones: That must be very gratifying to have the ability to give a woman that gift, not only as a reconstructive surgeon to give the gift of having symmetry and a self-image that will carry her forward as she works through her recovery but even having the ancillary staff that can help her through that like the tattoos and the counselors and therapists and all of the people, a whole team that can take care of people.

Dr. Agarwal: It's absolutely gratifying to see a patient go through this process and come out feeling whole again and feeling like they can get past or move beyond their initial diagnosis of cancer, and that's really the goal is to help them move forward in life.

updated: June 8, 2021
originally published: October 22, 2015