6 minute read
Improving breast radiation protection for female orthopaedic surgeons
Hannah Sevenoaks, Isobel Pilkington, Lynn Hutchings and Charlotte Lewis
Around 20 years ago, Dr Loretta Chou started noting cases of breast cancer among her orthopaedic colleagues in California. She undertook a series of studies, which indicated an increased prevalence of breast cancer in female American orthopaedic surgeons. Studies by other groups have shown the female breast is inadequately protected by standard radiation personal protective equipment (PPE), leading to concerns that female surgeons are being exposed to a higher risk of developing breast cancer.
In this article, we aim to outline the current evidence and explain how the British Orthopaedic Association are supporting ongoing work to improve breast radiation protection for female surgeons.
Breast cancer
Breast cancer is the commonest female cancer in the UK, with a 1 in 7 lifetime risk [1]. Radiation is estimated to cause 1% of breast cancers, as breast tissue is highly radiosensitive in a dose-dependent fashion. The majority of female breast cancers develop in the upper outer quadrant (UOQ) of the breast, which extends up to the axilla [2,3].
Breast cancer risk in orthopaedics
The epidemiological work by Chou et al. showed a 1.9-fold increase in all forms of cancer and a 2.9 to 3.9-fold increase in breast cancer in female orthopaedic surgeons, compared to age matched control populations. While this involved self-reporting, the increase was not seen in plastic surgeons or urologists and remained present even after sensitivity analysis to address selection bias [4-6].
Robust, longitudinal data pertaining to occupational radiation exposure risk is not available for female surgeons, due to historical low numbers and a lack of focus on data collection in this area. As such, the risks of radiation-induced breast cancer in surgeons is poorly understood [7]. However, occupational radiation exposure has been associated with an increased prevalence of female breast cancer in other healthcare cohorts, including US radiology technicians, Chinese radiographers and Finnish doctors [8-10]. Occupational radiation exposure has not been identified as a risk factor for male breast cancer [11,12].
Standard radiation PPE fails to protect the breast
Studies measuring radiation dose exposure in simulated surgical settings have demonstrated that current standard PPE designs provide inadequate protection to the UOQ of the breast. This is most pronounced with the C-arm in the lateral position and the surgeon standing perpendicular to the table [13]. Comparison of gown designs showed that traditional tabard gowns or loose-fitting vests made no significant difference in the protection afforded to the UOQ when compared to wearing no gown at all. Significant reductions were seen when formal axillary cover was provided [14].
Improving breast radiation protection in the UK
With the support of the BOA, a short-term working group was developed in late-2022 to address issues involved in radiation protection, particularly for the female surgeon. This work has involved a number of different avenues – examination of the current evidence, dissemination of appropriate information and working with industry to assess PPE options, which may improve breast protection.
Overall, the key radiation safety principle of time, distance and shielding remains the foremost way to reduce exposure, with PPE as an additional line of defence. Specific recommended behaviours are outlined in Table 1.
Table 1: Techniques to minimise surgeon breast irradiation specifically:
• Stand as far back from the source as possible
• Keep arms by side where able
• Stand square to the source to avoid exposing the axilla
• Reduce the use of direct lateral views
Prototypes of PPE with improved breast and axilla coverage have been tested for suitability in orthopaedic procedures, looking at comfort, fit, ability to move freely and extent of protection. Preliminary work has been done to test gown efficacy in simulated settings, with further research planned to establish levels of dose reduction.
What breast radiation PPE should we adopt?
Radiation protection guidance is now available on the BOA website, and we encourage surgeons and departments to reference this to explore the options available. Tabard gowns clearly provide inadequate protection for female surgeons and snapshots of current theatre provision across the country indicate provision will need to be updated in many hospitals. Local working parties may be best placed to consider hospital-level or regional requirements to ensure adequate protection for all surgeons.
Individual surgeons may have different preferences for breast and axillary coverage, based on body habitus, fit and nature of work undertaken. Surgeons should aim for:
A good, close fit
Comfortable and free movement of the arms
Axillary and breast cover are maintained with the arm abducted
Companies have been invited to the 2023 BOA Annual Congress to allow surgeons to trial available products.
Types of enhanced breast radiation PPE
Examples of garment types are:
Vest with axillary shields - A detachable shield is applied to the vest, encircling the axilla. Our team worked with industry to develop these, which are comfortable and have no visible gaps in protection. (Made by Rothband, UK).
Vest with sleeves - A fully integrated top with sleeves protecting the front and back of the axilla, providing comprehensive coverage. (Made by ProtecX, UK).
Vest with wings - Integrated wings on a well-fitted and comfortable-to-wear vest. The additional material fans out anteriorly, but does not wrap around the axilla to provide full coverage. (Made by Infab, USA; UK distribution via Platform 14)
Bolero - Lead sleeves with a lightweight mesh across front and back, which can be worn under a standard vest. While having the advantage of acting as an adjunct to current gowns, initial testing suggested these were less comfortable and had some gaps in protection, depending on individual shape. (Made by ProtecX, UK and Mavig, Germany).
Beyond T&O
Radiation protection for the breast clearly impacts on many specialities beyond orthopaedics. The European Society for Vascular Surgery has already recommended that female operators consider adopting enhanced protections. We hope that growing awareness across specialities drives industry and governance structures to recognise the importance of protecting the female breast from occupational radiation.
Conclusion
Education for all surgeons, male and female, is key to reducing exposure in theatres. Additionally, our aim is for all female orthopaedic surgeons to have access to suitable PPE to both adequately protect breast tissue and to retain flexibility for orthopaedic operating. We aim to continue evaluating products, to determine degrees of protection and to improve recommendations.
Acknowledgements
Many thanks to Deborah Eastwood, Fergal Monsell, Caroline Hing and Emily James for their ongoing enthusiasm, support and guidance.
References
References can be found online at www.boa.ac.uk/publications/JTO
Hannah Sevenoaks is a ST7 in the North West Deanery (East Sector). As a BOA/BOTA Culture and Diversity Champion, she is interested in addressing barriers to building a more inclusive orthopaedic workforce.
Isobel Pilkington is a Core Surgical Trainee in Wessex. She hopes to train in Trauma and Orthopaedic Surgery and ensure that all women working in healthcare are protected from ionising radiation.
Lynn Hutchings is a Consultant Trauma & Pelvic Surgeon at North Bristol NHS Trust. She is a breast cancer survivor.
Charlotte Lewis is a full-time NHS Trauma Surgeon. She trained in the Wessex region and has worked at Portsmouth University Hospital as a Consultant since 2012. She is currently the Past President of the Orthopaedic Trauma Society.
