Prevalence of Breast and Other Cancers in Female Podiatric Surgeons

Cancer poses a significant challenge to women’s health, casting a pervasive shadow over lives and communities across the United States. Breast cancer stands out as particularly daunting, exerting a heavy toll on individuals and society at large. The need to enhance prevention strategies against cancer becomes increasingly evident as we strive to mitigate cancer’s impact on women’s well-being.

There has been increased awareness concerning cancer development among female podiatric surgeons, a profession not typically associated with heightened cancer risks. The introduction of fluoroscopic surgeries into podiatry has brought to light an occupational hazard despite efforts to protect surgeons with lead vests and thyroid shields, along with maintaining radiation dose from fluoroscopy units as low as reasonably achievable (ALARA).¹ Based on the ALARA concept, the 3 major factors to reduce occupational exposure to scatter radiation are the time of exposure, the distance to radiation, and shielding from radiation.² Without these measures, vulnerable areas such as the armpit may be exposed, potentially facilitating the infiltration of harmful radiation. This subtle pathway of exposure raises profound concerns about the health and well-being of female podiatric surgeons, increasing their vulnerability to heightened risks of cancer, specifically breast.

Notably, demographics show that 37.1% of podiatric surgeons are women, underscoring the importance of addressing gender-specific risks in this profession.³ While studies have demonstrated elevated cancer risks among female orthopedic surgeons, particularly in breast cancer incidence, the direct relevance of these findings to podiatry remains uncertain. Moreover, with the evolving landscape of surgical techniques, including podiatric minimally invasive surgeries using fluoroscopy, there is an urgent need for contemporary investigations into the specific occupational hazards faced by female podiatric surgeons.

In navigating the complex landscape of surgical oncology, it is crucial to delve into the unique challenges encountered by female podiatric surgeons. By examining the intricate interplay among fluoroscopic surgeries, radiation exposure, and the heightened risks of cancer, particularly breast, we aim to prioritize the health and well-being of these invaluable healthcare professionals. While previous investigations have highlighted increased cancer prevalence among certain surgical specialties like orthopedics, urology, and plastic surgery, podiatry has largely escaped scrutiny in this regard.⁴ To date, we are unaware of any published study of the prevalence of cancer, specifically breast, amongst female podiatric surgeons. This study aimed to provide an updated prevalence of breast cancer and other cancers among female podiatric surgeons.

A Closer Look at the Study

Between March 2024 and April 2024, we conducted an online survey of female podiatric surgeons, including podiatric surgical residents, with a total of 194 participants. We contacted female podiatric surgeons via email, text messages, social media podiatry groups, and social media websites asking them to complete an electronic survey.

The survey designed aimed to gather data on various aspects including standard fluoroscopy utilization, mini-fluoroscopy usage, prolonged fluoroscopy application during procedures exceeding 10 minutes, current protective shielding practices, age, ethnicity/race, recent mammogram screenings, and cancer diagnoses. Demographic inquiries captured details such as age, race/ethnicity, body mass index, menstrual and reproductive history, and hormone usage. Professional queries focused on years of practice, which included residency, fluoroscopy usage, polymethylmethacrylate (PMMA) application, and lead protection measures. Cancer diagnoses were self-disclosed and elicited through specific questions such as: Have you ever been diagnosed with cancer? If you have been diagnosed with cancer, what type?

We additionally compiled data concerning the clinical practice specifics of female podiatric surgeons, encompassing their employment background and occupational radiation exposure levels. Radiation exposure was assessed through the examination of standard fluoroscopy usage, mini-fluoroscopy utilization, and PMMA application.

What the Study Revealed

A total of 194 female active female podiatric surgeons volunteered to participate in this survey. This study reported 15 women diagnosed with cancer (Table 1). One hundred thirty-one females were less than 40 years old, 38 were between 40–49 years old, 20 were between 50–59 years old, and 5 were 60 years old and above. The majority of the patients were white (59.79%), followed by Asian/Pacific Islander (19.0%), Black/African American (9.28%), Hispanic (6.70%), other or mixed (4.64%), and Ashkenazi Jewish (0.52%). Our sample size consisted largely of younger, white females.

The following types of invasive cancers were prevalent: breast, thyroid, ovarian, uterine, colon, and melanoma. In this group of 15 individuals with self-reported cancers, breast and thyroid were the most prevalent at 60% and 13.3%, respectively. We noted 68.04% of the female podiatric surgeons in this study reported using standard fluoroscopy almost never or ≤ 4 times per month, and 31.96% reported using it >1 time per week. Additionally, 49.48% of the participants reported using mini fluoroscopy almost never or ≤ 4 times per month, and 50.52% reported using it >1 time per week. There was no significant difference in both cohorts with the use of mini-fluoroscopy, and a majority of the podiatrists in this study did not use standard fluoroscopy. This would imply that the increased prevalence of cancers in female podiatric surgeons is not associated with the radiation alone, but more likely with the duration of use and/or lack of appropriate protective shielding. A majority of the cohort also did not report using PMMA or used it ≤ 4 times per month (93.3%). Of the 194 participants in this study, 33.9% reported using protective shielding almost never or ≤ 4 times per month, and 60.1% reported using it >1 time per week.

With the information gathered of 31.96% reported using standard fluoroscopy >1 time per week and 50.52% reported using mini-fluoroscopy >1 time per week in correlation of 60.1% reported using protective shielding >1 time, the percentage of female podiatric surgeons wearing protective shielding is deemed appropriate. This would also imply that the increased prevalence of cancers in female podiatric surgeons is not associated with the radiation alone, but more likely with the duration of use and/or lack of appropriate fitted protective shielding.

Correlating OR Radiation With Cancer Risk

With an increase in innovative podiatric surgical techniques requiring fluoroscopy for assistance, radiation may contribute as a hazard to surgeons. As a result of  this study, we contend that an increased prevalence of cancers among female podiatric surgeons may be correlated with prolonged exposure of radiation and inadequate protective measures. In the medical setting, proper fitting protective shielding and adherence to safety protocols are crucial factors that facilities and individuals use to mitigate the risks associated with radiation exposure. Among the 194 female podiatric surgeons surveyed, 15 indicated that they had been diagnosed with cancer, breast and thyroid being the most common types followed by ovarian, uterine, colon, and melanoma (Table 2).

There are 3 major factors in reducing scatter radiation doses: the time of exposure, the distance from the radiation source, and shielding from radiation. The most important among these factors is proper shielding.² A lead apron must be well-fit to maximize its effect. Valone and colleagues studied the etiologies of prevalent breast cancer among female orthopedic surgeons using an anthropomorphic torso phantom simulating the female surgeon.⁴ Authors found that when the lead apron was too large or too loose, the upper outer quadrant of breasts will receive much higher radiation dosage compared to the lower outer quadrant. The upper outer quadrant area of the breast is the most common site of breast cancer occurrence.⁵ It is also important to note that C-arm cross-table lateral projections cause higher breast radiation exposure than AP projection.⁴ It is of utmost importance that the lead apron fits the surgeon properly at the neckline and arm entrance. Protective shielding alone may not prevent cancer. The protective shielding must be the correct size, not loose, and without large gaps in the arm hole. Large gaps from improper fit could result in the increased exposure of breast tissue.² Using cross-back aprons provides higher protection than vest shield configurations.⁴

A large cohort study and survey found an increased prevalence of breast cancer among female radiation technologists, while another study showed a significantly increased risk of breast cancer for female radiologic technologists exposed to daily low-dose radiation for several years. A third study reported a 1.9-fold increased prevalence of cancer and a 2.9-fold increased prevalence of breast cancer in female orthopedic surgeons compared with American women of similar ages and races.² Therefore, aprons of appropriate size and proper fit should be provided to each provider.

Although the majority of female podiatric surgeons (68.04%) reported almost never or ≤ 4 times per month using standard fluoroscopy and (49.48%) reported almost never or ≤ 4 times per month using mini-fluoroscopy, there is still a risk of radiation exposure, especially with improper fitting protection. This risk may remain present even for the lower percentage (31.96%) who use standard fluoroscopy and (50.52%) mini-fluoroscopy more frequently.

The study on the prevalence of breast cancer and all-cause cancer among female orthopedic surgeons indicates a higher risk of breast cancer compared to the general population of women in the United States, with radiation exposure being the most likely cause.¹ Of note, inexperienced surgeons or those in early practice may be at a greater risk of prolonged fluoroscopy exposure and may not have access to appropriately fitting lead, putting them at a higher risk.² With the latest innovative techniques of minimally invasive surgery of the foot and ankle, increased fluoroscopy use may pose more risk of radiation exposure.

As per the American Cancer Society research study on cancer statistics, progress in reducing death rates for the 4 leading cancers (lung, colorectal, breast, prostate) is driven by long-term declines, although reductions have slowed for female breast and colorectal cancers and halted for prostate cancer over the past decade.⁴ One study noted orthopedic surgeons have a higher prevalence of breast cancer compared to women in the general US population.⁴ 

In Conclusion

Our study identified breast cancer as the most prevalent type of cancer among female podiatric surgeons. Breast cancer is the second leading cause of cancer death after lung cancer.⁷ There has been a slight rise in breast cancer incidence rates (approximately 0.3% per year) since 2004.⁸ Our survey findings highlight the fact that female podiatric surgeons should prioritize their own health and well-being via regular mammograms, wearing appropriately fitted lead shielding that is not loose and with no gapping about the arm hole, wearing thyroid shielding, and increasing awareness among all women.

There are limitations to this study. The study size is small since the time range for the survey was only one month. Another limitation was the age group, with the majority of the females in the cohort being less than 40 years of age. Future surveys should compare this data since minimally invasive surgery is an ongoing trend with a potential of increased radiation exposure time, especially in those less experienced. To minimize radiation exposure, hospitals and practices should consider providing light lead aprons which appropriately fit female podiatric surgeons, including covering the breast.

Lady Paula DeJesus, DPM, FACFAS, FACPM,CWSP is board certified by the American Board of Foot and Ankle Surgery, the American Board of Podiatric Medicine, and the American Board of Wound Management. She is the Chief of Podiatric Surgery at Yale New Haven Greenwich Hospital and a teaching attending Yale New Haven Bridgeport Hospital.

Rachna Bangdiwala, DPM, is board certified by the American Board of Podiatric Medicine and practices at Northwell Health in Plainview, NY.

Rupinder Boora, DPM, practices at Wyckoff Heights Medical Center in Brooklyn, NY.

Jenee Gooden, DPM, practices at Yale New Haven Health Bridgeport Hospital in Bridgeport, CT.

Aparajita Rajamahanty, DPM, practices at Wyckoff Heights Medical Center in Brooklyn, NY.

References

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