The first time Loretta Chou drilled a hole in a bone, as a medical student in the mid-80’s, she thought it was the most fun thing she had ever done.

“I liked that you could actually make people better—almost immediately better—by operating on a fracture,” she recalls.

When she decided to specialize in orthopedic surgery, the branch of medicine that treats the musculoskeletal system, she knew that her chosen profession was a boys’ club. Just six percent of orthopedic surgeons are women. But it didn’t dawn on her that her job could be a health risk until the mid-2000s, when Chou, by then the chief of foot and ankle surgery at Stanford University, noticed that an alarming number of female colleagues were being diagnosed with breast cancer.

She got to wondering: Was this a fluke, or did female orthopedic surgeons have high rates of cancer? On some level, it wouldn’t be surprising if they did. Radiation exposure is a known carcinogen—the closer you are to the radiation source, the higher the risk—and orthopedic surgeons are often the closest in the operating room to x-ray beams. The surgeries typically involve the use of a technology called fluoroscopy, which shines an x-ray beam onto the patient during operations, providing the surgeon with real-time images over the course of the operation. The procedures can be lengthy, exposing surgeons to radiation over several hours. Yet surgeons aren’t always diligent about wearing the lead shields aimed at protecting from radiation, and, critically, the shields often leave the outer edges of the breast uncovered.

Chou’s latest study found that the surgeons have rates of breast cancer nearly four times higher than the general population.

In the summer of 2007, Chou and her colleagues at Stanford mailed surveys to the women in the American Academy of Orthopaedic Surgeons, the field’s main professional association, asking if the surgeons had had cancer. More than eighty percent of the recipients, or 499 women, responded; 29 of them had a history of cancer. While the sample size was small, the results, published in the Journal of Bone and Joint Surgery, were startling, suggesting that female orthopedic surgeons were nearly twice as likely to have cancer as women in the general population, and nearly three times as likely to have breast cancer. A follow-up study of similar sample size in 2012 had nearly identical findings. Another, in 2015, found significantly higher rates of breast cancer among orthopedic surgeons than plastic surgeons or urologists, both of whom generally use fluoroscopy less frequently than orthopedic surgeons. Chou’s latest study, a survey of nearly 700 female orthopedic surgeons published earlier this year, found that the surgeons have rates of breast cancer nearly four times higher than the general population.

These findings come with a number of important caveats. The sample sizes are small, and the studies were based on voluntary surveys, which may elicit more responses from people who have had cancer. The breast cancer rates, as high as they may be, may not be caused solely by radiation. Due to the demands of the job, orthopedic surgeons tend to have kids later and to spend less time breast-feeding children, both of which are risk factors for breast cancer. (The studies controlled for age, but not for reproductive status.)

Even with the limitations, the breast cancer rates among orthopedic surgeons are “enough of a signal to say we really need to study this further,” says Dr. Rebecca Smith-Bindman, an epidemiologist and radiologist at University of California-San Francisco who studies the risks of diagnostic imaging. “There’s no uncertainty about radiation causing cancer,” she says, “and it always strikes me that physicians are not nearly respectful enough of the radiation.”

The number of procedures guided by fluoroscopy have skyrocketed in recent years, multiplying 31-fold between the 1980s and the 2000s. Its use isn’t limited to surgeons; many other kinds of doctors, particularly cardiologists and radiologists, rely heavily on the technology. Research into which medical professionals have the highest rates of radiation exposure and cancer is patchy at best, but the existing studies suggest that those working with fluoroscopy are at higher risk of health complications. One of the rare, large-scale longitudinal studies to look at cancer rates among medical workers found that radiation technologists who assist with fluoroscopy procedures have double the rates of brain cancer and higher rates of breast cancer compared to those technologists who do other kinds of imaging work.

“I’m standing right next to the x-ray machine, and I’m going, ‘The arm hole on this goes down pretty much down to my waist.'”

To understand the particular risks of radiation to women, picture an operating room scene. As a surgeon operates, a fluoroscopy beam shines on the patient. When they’re operating on smaller body parts, like hands and ankles, surgeons often use what’s called a mini-fluoroscopy, enabling them to control the strength and angle of the beam using a combination of buttons and foot pedals. In other cases, surgeons direct radiation technologists on when and where to shine the beam. The resulting images, displayed on a monitor, allow the surgeon to track her progress, ensuring that bones are aligned correctly and screws are put in the right place. For protection, hospitals provide lead aprons, which look like long, heavy tank tops, for medical workers to share. But radiation is a bit like light: It scatters. And during surgery, it may be scattering at close range of the surgeon’s armpit, which, with a traditional lead apron, can leave parts of the breast vulnerable.

Having access to a well-fitted lead apron is the best practice, but often not the reality: The available apron may be the wrong size, leaving gaping holes in critical areas, or it may have cracks from not being stored correctly. The lead is heavy and hot, and sometimes, doctors decide it’s easier to not wear it at all. “When we’re young, we don’t think about it,” says Dr. Antonia Chen, an orthopedic surgeon at Harvard’s Brigham and Women’s Hospital. “A lot of times, we don’t put lead on. We just say, ‘Suck it up and do it.’” Chen, who co-authored the most recent survey study with Chou, was herself diagnosed with breast cancer as she was submitting the study for review.

In 2011, when Lindsey Valone, a hand surgeon in San Francisco, was in medical school, she heard Chou present her study findings about breast cancer rates at a conference. She was alarmed to hear about high cancer rates in the field she planned to go into. “I went back to my institution, and the only lead shielding they had available were these enormous, extra-large aprons,” she remembers. “I’m standing right next to the x-ray machine, and I’m going, ‘The arm hole on this goes down pretty much down to my waist. There’s no way any of my breast tissue is being protected right now.’”

In 2016, Valone and her colleagues conducted a study, positioning a dummy simulating a female surgeon next to an operating table, where fluoroscopy imaged a dummy patient. The results, published in the Journal of Bone and Joint Surgery in 2016, were telling: If a lead apron was too small or too big, particularly if the x-ray beam was coming from the side, which is common during surgeries, then the area around the armpit was left vulnerable to radiation. That area includes the upper outer quadrant of the breast—the most common site of breast cancer.

“Before I did the study, my armpit would be right next to the x-ray source,” says Valone. “That’s how we did it in training. Now, I’ll turn my body 90 degrees, so anything scattering will hit the front of the lead apron, where I’m most protected.”

Aspiring surgeons learn about radiation risks in general, but there is no training specific to the risks that women face, according to a spokesperson for the American Academy of Orthopaedic Surgeons. None of the ten female orthopedic surgeons I spoke with for this article learned about how to mitigate breast cancer risks in their formal training. Several didn’t know about the high rates of cancer in their field until they were diagnosed with the disease. The American Academy of Orthopaedic Surgeons appears to have featured just one talk on breast cancer risks among the thousands of presentations given at the group’s conferences.

“If I knew it was a risk, then I would have checked more and maybe caught it sooner.”

“No one had mentioned increased risk of cancer with my profession,” says Dr. Emily Zhao, a 33-year-old foot and ankle surgeon in Boston. In the fall of 2020, Zhao was diagnosed with breast cancer. She underwent chemotherapy, a double mastectomy, and radiation in quick succession. Earlier this year, she learned that the cancer had metastasized to her brain. When we spoke, in July, doctors estimated she had two months left to live. Zhao is the first to say that she’ll never know what caused her cancer. Perhaps it was genetics, or something about her lifestyle, or simply bad luck. But she regrets that she didn’t have more training on radiation. “If I knew it was a risk, then I would have checked more and maybe caught it sooner,” she says.

A concerned surgeon could, in theory, buy her own lead apron and equip it with what are known as wings, which look something like caps on sleeves. But a study published last year found that the wings do little to shield the upper outer quadrant from radiation. The ideal protection for the breast, according to the study, is an apron with an “axillary supplement”—which looks like a tight-fitting tank top with a flap under the arm that shields the armpit. The problem is, such shields don’t exist. The authors made their own for the purposes of the study.

“I think it’s basic economics at play here,” says lead author Dr. Sara Van Nortwick, a spine surgeon at the Medical University of South Carolina. “Women are a minority as surgeons and haven’t been advocating for the safety and protection they need, nor has this been studied very well or very much.” Even Van Nortwick doesn’t have axillary protection when she operates; she doesn’t know how she would go about getting it. “I would literally have to buy something else and tape it on there or something,” she says.

The American Academy of Orthopaedic Surgeons appears to have featured just one talk on breast cancer risks among the thousands of presentations given at the group’s conferences.

The barriers to better protection for women aren’t just mechanical—they’re also cultural. “There’s a little bit of a cowboy mentality in healthcare: ‘We can do this, we don’t need those shields,’” says Smith-Bindman, the UCSF epidemiologist.

Several female surgeons noted that, in such a male-dominated field, they didn’t want to be the squeaky wheel, complaining about lead shielding.

“As a woman, as a female orthopedic surgeon, I want to be seen the same as the rest of the guys, right?” says Chen, the Brigham and Women’s surgeon. “But our breast cancer risks are higher than men. Period. There’s no way around it.”

In the absence of formal training, some surgeons have taken matters into their own hands, imploring their younger colleagues to use lower doses of radiation, to step away from the x-ray when possible, to position themselves perpendicularly to the beam, and to get early screenings for breast cancer. Among them are Dr. Evalina Burger, the chair of orthopedics at the University of Colorado School of Medicine. Burger, 62, is one of just four female orthopedic department chairs across the country. When Burger was diagnosed with breast cancer, she, too, was startled to learn about rates of cancer in her profession. “Everybody was like, ‘Oh, we’re really sorry for you,’” she remembers. “But I was very concerned about the fact that other women should know about this to better protect themselves.” Now, Burger leads a group for prospective female orthopedic surgeons at the University of Colorado. In addition to practicing using drills and scalpels, the women talk about the risks that come with the job.

“Would it have changed my decision to be an orthopedic surgeon?” says Burger, “No. Would I have taken better precautions? Maybe.”