Breast cancer risk

We recognise that the orthopaedic community have diverse gender identities.

Here, we use the terms female and male to refer to biological sex, in line with the scientific literature relating to breast cancer.

1. Incidence and risk factors

Breast cancer is the most common female cancer in the UK, and the second highest cause of female cancer mortality, accounting for 11,000 deaths per year.

Women in the UK have a 1 in 7 lifetime risk of breast cancer. The overall cancer incidence has increased since the 1990s, with the highest increases seen in the working age population. Breast cancer now accounts for 43% of cancer cases in women aged 25-49 years [15].

Many breast cancer risk factors are not modifiable, and include increasing age and genetic predisposition. However, 23% of breast cancer cases are deemed preventable, with 1% attributable to ionising radiation [15,16]. The IARC have defined ionising radiation as having 'sufficient' and 'convincing' evidence as a breast cancer risk factor.

Female breast tissue extends into the axilla and the majority of breast cancers occur in the upper outer quadrant (UOQ) [17].

2. Risk in orthopaedic surgeons

The current risk of breast cancer in orthopaedic surgeons is unknown. As the proportion of female orthopaedic surgeons increases, we must continue to collect data to assist in clarifying whether an additional risk of breast cancer exists. There have been no reports of an increased risk in male surgeons, as they have no breast tissue extending into the axilla [18].

Two self-reported US studies of female orthopaedic surgeons have shown a 1.9 fold increase in all-cause cancer incidence and a 2.9-3.9 fold increased incidence of breast cancer. This increase was not seen in plastic surgeons or urologists, and remained when the cohort was matched against a control population [8-10].

Occupational radiation exposure has been associated with increased prevalence of female breast cancer in other healthcare cohorts, including US radiology technicians, Chinese radiographers, and Finnish doctors [5,19,20].

3. Current PPE and effectiveness

Currently available PPE consists of tabard-style one piece gowns or a two piece skirt and vest. Simulated studies measuring dose exposure to the UOQ of the breast have shown that these provide inadequate protection, particularly with the C-arm in the lateral position, and the surgeon standing perpendicular to the table [21].

Dosimeters worn over these gowns showed the area next to the axilla and UOQ received the highest dose of radiation in the torso [22].

Studying different designs in a simulated setting showed no reduction in radiation exposure to the UOQ and axilla in a standard tabard gown when compared to no gown. Significant reduction could be achieved with the use of sleeves and axillary shields [23] and at the present time, we recommend:

  • Use of a well-fitting vest with arm holes, as close to the axilla as is possible to fit comfortably
  • Avoidance of a tabard-style gowns, which gape at the sides

Provision of axillary and UOQ coverage have traditionally involved custom-made designs, using sleeves or axillary shields. Axillary wings have been promoted in the USA, but have not been shown to reduce axillary exposure in simulated settings [23].

Radiation gowns 2.jpg
4. Developing axillary protection

A team has been working with partners in industry to produce a design that is comfortable for female orthopaedic surgeons, covers the lateral chest wall and axilla and protects the UOQ and axillary tail. Options under consideration include axillary shields, vests with sleeves, bolero tops to be worn under standard vests, and vests cut to fit high into the axilla. The aim is to develop a commercially available option that does not require custom fitting, and can therefore be made available to all female surgeons.  We have been trialling currently available and design prototypes and plan to evaluate them in a simulated setting to quantify reduction in radiation exposure to the axillary tail of the breast.

Radiation gowns.jpg



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