Search for tag: "breast cancer"

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.

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.

Announcer: Want The Scope delivered straight to your inbox? Enter your email address at thescoperadio.com and click "Sign Me Up" for updates of our latest episodes. The Scope Radio is a production of University of Utah Health Sciences.

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

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Dr. Miller: Self-breast exams can be a very important part of preventing breast cancer, at least detecting it early enough that it doesn't become as big of an issue as it might. We're with Jenna Andrus and Karen O'Toole from Huntsman Cancer Institute. They're in the Patient and Public Education Department, here to talk about an app called Check Yourself. I think that the app says it all, but let's talk about it a little bit further. Jenna, what is Check Yourself?

Jenna: So Check Yourself is a free app that you can download onto your phone that basically provides some instruction on how to perform a self breast exam and then will establish some reminders to do it on a monthly basis.

Dr. Miller: And Karen, tell us a little bit about the app that you know. Did women seem to like it? Is it an effective app? Is it a good app?

Karen: I think it's a very easy, simple app to use. It shows you at the very beginning mirror mirror. So one of the most important things to do is to look at yourself in the mirror, and if you're not going to do a breast exam . . . But at least look at yourself and know your breasts.

Dr. Miller: And it tells you what to look for?

Karen: Yes, it does.

Dr. Miller: Okay, great.

Karen: I think most women find a lot of lumps in the breast and I think that's really frightening. And this doesn't go through what you're looking for. It just shows you how to do it. And that's the whole point of the app, is to get to know your breasts.

Dr. Miller: And how about the reminder portion? That sounds like that could be really useful because a month can go by pretty quickly.

Jenna: Yeah, you're right. It's amazing how you can just quickly forget how time flies. So the reminder, you can set it up to email you every month or also to text you, so you have both of those options there. And it's pretty nonintrusive so you can set it up pretty easily.

Dr. Miller: One of the things about any app is, is this legitimate? Is it based on actual science, best information? Karen, is this app based on those things? What's your feeling on that?

Karen: Yes.

Dr. Miller: It is.

Karen: Yes, it certainly is.

Dr. Miller: Yeah, so it's an app that a woman could trust.

Karen: Yes.

Dr. Miller: What would be the most important thing to take away from this conversation? I'm going to start with you, Jenna.

Jenna: Yeah, I think just to be aware of your body overall and, like we've mentioned, be aware of your breasts and changes in them and then particularly to talk to your doctor if you are concerned about something, which the app does clarify at the end. If you do have something that is concerning, please talk to your doctor because we know that not all lumps mean that it's breast cancer.

Karen: I think what Jenna said is right on, just becoming familiar with your own breasts and know the lumps and bumps and which breast is bigger than the other and what's normal for you. And that's going to be different.

Dr. Miller: Do you find a lot of women don't know these things? I would think that they would.

Karen: No, I think a lot of women are frightened or they just forget. And I think this app is good for that reason.

Jenna: It's really important to talk to your doctor about it.

Karen: Yes.

Jenna: So if you're not comfortable doing it, be sure that you see your doctor once a year to have them perform just the exam in their office to help do that screening for you. And of course, if they see anything that is concerning, they're going to refer you to some further diagnostic testing.

Dr. Miller: So whether it's you or somebody else, this is just something that you should be doing.

Jenna: Yeah, yeah.

Karen: And with all the screening guidelines out there, again, it's really important to talk to your doctor because a lot depends on your family history. And if you do have a history of breast cancer, it changes as far as screening goes.

Announcer: TheScopeRadio.com is University of Utah Health Sciences Radio. If you like what you heard, be sure to get our latest content by following us on Facebook. Just click on the Facebook icon at TheScopeRadio.com.

Gretchen: A breast cancer diagnosis can feel like a body blow to anyone. Kimberly Myers, PhD, from the Penn State College of Medicine is here to tell us why one of her first responses to her own diagnosis was to meet with a professional photographer to document her body. That's coming up on The Scope.

Announcer: Medical news and research from the University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Gretchen: Hi, I'm Gretchen Case from the Division of Medical Ethics and Humanities at the University of Utah School of Medicine, and I'm here with Kimberly Myers. So my first question for you is why did you want to meet with a photographer? Why was that one of your first thoughts?

Dr. Myers: I think when one gets diagnosed with breast cancer one's mind goes just goes blank in many ways. But one of the things I did know was having had no photographs of my breasts, I wanted to know what I would look like after surgery. I knew that I had a very short window of time in which to get photographs, if I were going to do that. A friend of mine suggested Wendy Palmer, a professional photographer.

Gretchen: So you wanted to be able to remember with photographs what your body had looked liked before you moved on.

Dr. Myers: Yes, because I was convinced that I wanted bilateral mastectomy.

Gretchen: So when you met with Wendy, what was that experience like?

Dr. Myers: It was a bizarre experience. Wendy and I had never met in person and I was going to her studio for the photo shoot. She had said, "Bring scarves and jewelry and bring music. I'd like for you to dance. We won't pose this." And so it was three hours of, first of all, meeting someone completely new and then going through various stages of undress to the point of being completely nude and having oneself photographed. It's something I would never have expected that I would do and she got some amazing photographs.

Gretchen: And then you had an idea about where this might go further. Can you talk about that?

Dr. Myers: Right. So I had a partial mastectomy and then went to chemotherapy. I had decided that one of the things I wanted to do with Wendy's photographs is to go through them and select one to have made into a portrait. Wendy and I, again, after I was into and almost through with chemotherapy, we got together and we looked through the 440 photographs that she had taken that afternoon, and I was struck with the range of emotions that she had captured. She's a phenomenal artist and I thought, I mentioned to her that so many of these feelings and moods were things that perhaps other people could relate to in their breast cancer experience.

We began a conversation about what we might want to do and that's when we decided that she would at least come and photograph subsequent stages of the process so that we would have the primary material if we wanted to do anything with it.

Gretchen: So what you ended up with is a series of photographs that goes from just days after your diagnosis all the way through your surgeries, your treatments, and your reconstruction.

Dr. Myers: Right.

Gretchen: Can you tell us how you went from taking these pictures for yourself to creating an exhibit that has gone around the country and is likely to go around the world?

Dr. Myers: It's strange when you put something out in the universe what happens sometimes. I think many, many people who go through breast cancer have this commitment to do absolutely whatever they can to help other women. Education has always been my passion and so my great desire going through this experience was to do whatever I could to help educate and encourage women about this.

We selected photographs that captured different moods and different dimensions, different parts of the process of reconstruction. It's a 30 piece exhibit and it's paired with verbal reflections that are very, very brief, like verbal snapshots that complement the visual images and those were added when I was looking back at the images. So it was well after the fact, months after the fact, when I was looking at the images and remembering what I would have been feeling like in those particular shots.

Gretchen: And what do you hope for someone to see or to take away from this exhibit? What do you want people to take away?

Dr. Myers: The main thing I want people to take away is a feeling that a diagnosis of breast cancer is not a death sentence necessarily, and it's certainly not something that will make a person into a monstrosity. I think many women are very concerned about losing a vital part of their femininity and aren't really aware that the cosmetic result can be really wonderful. That said, I also would never want to imply that my experience or the results I was fortunate enough to have would be the same experience and results that other women would go through. I think it's very individual.

Announcer: Interesting, informative, and all in the name of better health. This is The Scope Health Sciences Radio.

Interviewer: You just got home after your breast cancer surgery. What should you expect and what should concern you? That's next on The Scope.

Announcer: Medical news and research from University of Utah physicians and specialists that you can use for a happier and healthier life. You're listening to The Scope

Interviewer: When it comes to getting home and after your breast cancer procedure, what's normal and what's not normal and what should you expect? Hopefully we'll make this next part of your journey a little less scary. Dr. Cindy Matsen is a breast cancer surgeon at Huntsman Cancer Institute. She's going to help give you some idea of what to expect after you get home after your breast cancer procedure. So a woman gets home, what's normal? What's not? Let's start with what's normal.

Dr. Matsen: So what is normal is that regardless of the type of procedure you have, whether you have a mastectomy or lumpectomy, you will have some pain. That's a fact of surgery. So we make sure that we send you home with some pain medication to help with that. You should take the pain medication if you're feeling like you're having more pain than you can handle with something like Tylenol or ibuprofen. If you're ever having a dramatic increase in your pain, we want to hear about that, because that could be a sign that something abnormal is happening and we want to hear from you.

Interviewer: Generally, is it just a couple of different possibilities if you're getting a lot of pain? I mean, what is that abnormality?

Dr. Matsen: So usually if you're getting a lot of pain, it's a sign of bleeding or infection. Early on, it would typically be if you have a lot of swelling and pain we would be worried about bleeding. If you're having a lot of redness and swelling and it's further out from surgery, then we would be more worried about infection.

Interviewer: Everyone experiences pain differently. On a scale of one to ten, I mean how do you even determine if the amount of pain I'm feeling is abnormal?

Dr. Matsen: Right. So what I tell most women if they have a lumpectomy, is that they will probably be sore, not necessarily out of control pain just soreness, for a couple of days. In fact, they will only need the narcotic pain medication for a day or two at most. If women have a mastectomy, especially with reconstruction, they will need pain medication for a longer period of time because that's a much more painful procedure.

Interviewer: Because it's a lot more invasive, you're doing a lot more stuff.

Dr. Matsen: Right, it's a bigger surgery. It's a bigger incision, and it's not necessarily the bigger incision that hurts but just the surface area that is involved. And with reconstruction, especially if it's an expander that's placed behind the muscle, that's quite painful because it's stretching the muscle. So most women, that's where most of the pain is from. It's not actually from the mastectomy, but actually from the reconstruction.

Interviewer: I would imagine that of course, you should always consult your doctor and in this podcast here we're just talking about possibilities, but if there's ever any concern, probably pick up that phone. Is that what you would recommend?

Dr. Matsen: Absolutely, and we always provide women with phone numbers that give them access to someone 24/7, so if you're ever concerned, you wake up in the middle of the night and you feel something really abnormal, we have someone available to talk to you about that.

Interviewer: All right, so we've talked about pain, what are some of the other considerations?

Dr. Matsen: So the two main considerations that we have after surgery are the two things I mentioned with the pain are bleeding and infection. If you ever have an abnormal amount of swelling, we want to hear about that. Typically, if you call us and you say, "I'm having a lot of pain and a lot of swelling," we're going to say come in so we can take a look and see what's happening. If you're ever having fevers and swelling and redness, those are signs of infection and we want to hear from you then too because we're going to have you come in so we can take a look and possibly start you on antibiotics.

Interviewer: And are there differences if you've had a lumpectomy or a mastectomy as far as other things that you should be concerned about?

Dr. Matsen: There are differences. The main difference is that with a mastectomy, you go home with drains in and those drains have to be emptied a couple of times a day and you have to keep track of how much is coming out. If you ever see changes in the fluid, either in what it looks like or how much is coming out, we want to hear about that as well because that could be a sign that something has happened or changed that we need to hear about.

Interviewer: What are some common misconceptions when women get home? Like kind of like false alarms, if you will.

Dr. Matsen: I think the biggest thing is most women with a mastectomy and the drains get very concerned about the drains and the drain output is supposed to go down over time, but they'll be concerned that if it's going down that something bad is happening. And that's actually not, that's a normal part of the process. Your body makes fluid after surgery and as your body heals and those spaces closed down, the fluid will decrease with time.

Interviewer: All right, any final tips or any final thoughts on this topic?

Dr. Matsen: The biggest thing is that for most women, they've never had surgery before. They have no idea what to expect. We try to give you an expectation for the things to look out for, but if there's ever anything that you're concerned about, ever anything that you feel like may not be normal, we want to hear from you.

Interviewer: Better to make that phone call than go on the Internet and try to find out for yourself.

Dr. Matsen: Absolutely.

Announcer: Thescoperadio.com is University of Utah Health Sciences Radio. If you like what you heard, be sure to get our latest content by following us on Facebook. Just click on the Facebook icon @thescoperadio.com.

Interviewer: Can men get breast cancer? Turns out the answer is yes. Find out more about that next on The Scope.

Announcer: Medical news and research from University Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: Ginger Johnson is the president of GetScreenedUtah.com. Mainly, you're an advocate for women getting screened for breast cancer, but I was surprised when you said that I actually could be at risk for breast cancer. How common is that?

Ginger: It's not very common, but it is possible. Men are a little bit different. Their lifetime risk of getting breast cancer is about 1 in 1,000. But the interesting thing is that a lot of guys aren't even aware that if they have a family member, a blood relative that has breast cancer that their chances of getting that actually increase. And so it's very important for guys to be aware that they have pecs. Those pec muscles can also have fatty tissue over them, that is breast tissue. And that tissue can be susceptible to disease, just like a woman's breast can be susceptible to disease.

Interviewer: So, as a man, if I tend to be a little bit heavier and have more fatty tissue, does that increase my risk?

Ginger: Fat is an interesting thing because fat tends to hold onto hormones. And so those hormones can actually trigger different kinds of cancer in your lifetime. That's why women are tested if they're estrogen or progesterone positive or negative when they get a diagnosis of breast cancer. But what we're finding is that guys aren't aware that if they have a lump on their chest, they just kind of blow it off. They won't go and say, "Hey, is this something that I need to look at?" Because they don't have the knowledge to even think, "Oh, this might be breast cancer," because it's such a foreign idea to them.

Interviewer: Yeah. It's fairly rare. Not a lot of guys are diagnosed with it, right?

Ginger: Not a lot of guys are. It's 100 times less common among men than among women. But, what we're seeing is that there are still about 2,000 new cases of invasive breast cancer that are going to be diagnosed this year.

Interviewer: So I'm sure you noticed that I started checking myself . . .

Ginger: You did.

Interviewer: Right?

Ginger: That's okay.

Interviewer: So is that what a guy should do? Is it, you're looking for a lump?

Ginger: Breast cancer can show up in a lot of different ways. There are actually 12 different ways that it can show up beside a lump. A lump, of course, is something that is very easy to see. You can feel it. But, it doesn't have to be a big lump. It can just be something small, like a pinhead, even, that's hard and immovable. If you think about breast tissue as, maybe, like a lemon. There's a great campaign on WorldWideBreastCancer.com that actually shows lemons. And, this is a great way for guys to really . . . that this can be, too. But, in their analogy of a lemon, you're looking for a bad seed. So it's going to be hard. It's going to be immovable.

It's going to be something that you go, "Oh, this, this isn't soft," like a bean, or something squishy, which could be fat tissue, or even a lymph node. This is actually hard and immovable.

Other symptoms, though, could be redness on the skin, itchiness that does not go away, hotness. If you feel like you're seeing erosion on the skin, or if your skin is starting to invert or look like an orange peel. There are a lot of different changes that can happen on skin. This is for men and women.

Interviewer: Okay.

Ginger: But, a lot of times guys don't get this education.

Interviewer: Yeah. Sure. I never would have thought that a rash could be something like male breast cancer.

Ginger: If it doesn't go away, it's always best, if it doesn't go away, if it stays consistent over the course of a couple of weeks, go in and get it checked. Just go so you can know and figure out what it is. Because, you definitely want to find it before you feel it.

Interviewer: So, are you recommending guys do self-exams? Are you recommending that they just be aware?

Ginger: I would say I would be aware. Because you are less at risk, I would just say, "Be aware of your tissue."

Interviewer: Okay.

Ginger: Be aware of your body. I would, honestly, talk to your doctor. I mean, guys don't often go into the doctor, we know how that is. But, if you're going to go in and talk to your doctor, and if you do have a family history of a mom, or a sister, an aunt, somebody in your family, just say, "Hey, Doc, what is this? Tell me what you know." Now, if the doctor you go to does not know, then you're going to want to do some research on your own because oftentimes doctors, themselves, we love them, they do as much as they can with the knowledge they have, but sometimes they might not have the knowledge for you. So you might need to get a second opinion.

Interviewer: Yeah. It might not necessarily even be on the radar . . .

Ginger: It's true.

Interviewer: Because it is, it does happen, but it is somewhat rare.

Ginger: It's true.

Interviewer: So, do guys then get mammograms, at that point? Just like a woman would?

Ginger: They would. They would have to go in . . .

Interviewer: Really?

Ginger: And have, have some kind of a mammogram, a ìMan-o-gramî if you will. But, they might do an ultrasound. There might be some other things that they're going to do for you. But there have been gentlemen that I know that have actually had mastectomies, where they've had to have that tissue removed. Now, it seems foreign to a guy to do that. But, they've actually had to go in and remove that breast tissue that is over the muscles so that they can remove any disease from that person.

Interviewer: All right. Any final . . . I don't know what else to ask at this point, other than, I'm going to start paying attention. And if I see something that's not going away, or feel any weird lumps, I'll talk to my doctor. And I'll know that if my doctor is, "What?" then I need to, perhaps educate myself. Anything beyond that?

Ginger: That's . . .

Interviewer: As a man?

Ginger: That's the best thing, and to realize, guys, how much influence you have in the women in your life. I don't think guys realize that the influence they have to say, "Hey, women, this is something that we all need to be concerned about. If I can get it, then obviously you can get it. Go in and get your mammogram." That's something they recommend for women, age 40 and over, to start with that baseline, and go regularly thereafter.

Announcer: TheScopeRadio.com is University of Utah Health Sciences Radio. If you like what you heard, be sure to get out latest content by following us on Facebook. Just click on the Facebook icon at TheScopeRadio.com.