Martha, a public health consultant in Rhode Island, was a 36-year-old new mom who was still breastfeeding her 10-month-old when she was diagnosed with breast cancer.
Among the wrenching decisions Martha (who asked that her full name not be used) faced — all on cancer's tight, stressful timeline — were: whether to get a single mastectomy (as was recommended) or to remove the second breast as well for prophylactic reasons; whether, if she removed one or both breasts, to then undergo breast reconstruction or remain flat; and whether, if she removed both breasts and opted for reconstruction, which type to choose — implants or DIEP flap (which takes a flap of abdominal skin and fat and transplants it to the chest wall).
She decided on a double mastectomy with reconstruction. When she met with the plastic surgeon, she remembers "still being in shock that I had cancer and her handing me pamphlets, 'This is what a flap looks like.' … It just felt so insignificant compared to getting the cancer out," she recalls for Yahoo Life. "I don’t know if I really gave it a lot of thought. The flap surgery to me looked like it would be painful and with a difficult recovery, so I ruled that out quickly. So I said, 'OK, I guess I’m getting implants.'"
When she turned to friends and family for support, Martha was surprised to find she felt judged by some.
"There were some women in my life who at the time … made me feel vain for wanting to get the implants instead of just, like, focusing on the cancer. And I guess for me it was sort of a package deal," she says, adding that while she felt pressured from her doctor to get reconstruction, she heard from some friends that she should forgo it. "The best was, 'That's an elective surgery.' I mean, theoretically it is, but in my mind, it wasn’t," she says. Because of this experience, she adds, she has generally not shared with others when she's since had to go back under the knife for revision surgeries (as is not uncommon with reconstruction) or to have implants swapped because of a recall.
Martha isn't alone when it comes to feeling judged for her breast cancer treatment-related decisions.
When Ellyn Winters-Robinson, an Ontario, Canada-based publicist, was diagnosed, she opted for a double mastectomy and no reconstruction. "But my family and friends definitely challenged me on my decision initially, reflecting societal expectations that women should have breasts," she tells Yahoo Life. "They were supportive but confused and unaware of the difficulties associated with reconstruction after a mastectomy. Even my own doctors — my medical oncologist and radiation oncologist — were baffled I chose to stay flat, one remarking, 'But you are so fashionable.'"
Meanwhile, a 49-year-old Texas woman (who asked that her name not be used) faced similar reactions to wanting to go flat after her double mastectomy. "I had pushback from two breast surgeons saying that I would have 'major psychological problems' and was 'mutilating' my body," she tells Yahoo Life. It was only after tracking down a top-surgery doctor through a friend with a transgender son that she was able to have the procedure she wanted without judgment.
"At the heart of it," she says, "I think the medical system is patriarchal-based and surgeons are known for having big egos and not having the best bedside manners."
Also, notes Martha, "Breast cancer is one of the cancers that’s just so public … and maybe because you can see if someone’s had reconstruction or not, people get all up in your business. It’s like people asking you about your birth story — they feel like they should be able to ask." Then, depending on the answer, some feel entitled to offer "some sort of indictment or comment on what kind of mother or woman or feminist you are," she says. It gave her yet another worry: "Will people think I’m not a feminist if I get implants?"
Why breast cancer is different
A major factor, experts say, is how breasts in general are viewed in our society — and why, of all the known cancers, those affecting the breast are in a category of their own.
"Breast tissue isn't just physiological matter," Anne Marie Champagne, a junior fellow with the Center for Cultural Sociology at Yale University, where she is a doctoral candidate in sociology examining how a mastectomy informs a range of perceptions, tells Yahoo Life. "Breasts are medicalized, legislated, gendered, politicized and highly sensitized fleshy matter riven with public as well as deeply personal meanings." While our choices around them "may be individual and motivated by personal aims, beliefs and meanings," she says, they cannot help but be impacted by society at large.
She adds, "Breast cancer and this question of what a survivor does with their chest following a mastectomy is part of a collective narrative regardless of how isolated any one survivor might be."
Mary Ann Cutter, professor of biomedical ethics at the University of Colorado at Colorado Springs, agrees that this is why breast cancer is "different from a lot of cancers." The author of Thinking Through Breast Cancer: A Philosophical Exploration of Diagnosis, Treatment, and Survival, and a survivor of the disease herself, Cutter adds: "My recollection of what I experienced is a pressure to decide a number of important things in a short amount of time under conditions of clinical uncertainty. … And yes, I did find that suddenly I felt the pressure of deciding courses of clinical action that reflected my commitments — to me, my identity as a wife and woman and mother, and to my feminist friends."
In a New York Times op-ed, hospice nurse and author Theresa Brown declared, "The association of femininity and breast cancer is pernicious, because it genders the disease, meaning that a diagnosis of breast cancer marks patients as women first, people second. It implies that our womanliness is diseased, not our bodies.”
That was echoed in a 2019 article in the journal Plastic Surgery, which noted, "In contemporary North American culture, the female breast is among the most consequential symbols of femaleness."
That piece, written by three women in the department of surgery at the University of Calgary, pointed out: "Some women like their breasts, others hate them, and others try to ignore them, but the relationship between a woman and her breasts is rarely neutral. Those working in the field of breast reconstruction and those considering whether or not to undergo such surgery are wise to consider that the decision about whether to undergo breast reconstruction is not taken in social isolation nor is it merely 'personal.' Instead, such decisions are embedded within a socio-cultural and historical context and are often fraught with tensions that may not be apparent on the surface."
The fact is a mastectomy, explains Champagne, co-editor of Interpreting the Body: Between Meaning and Matter, forces breast cancer survivors to "grapple with and possibly redefine, both individual and collectively, what breasted matter means." Which is challenging as, she contends, "we are all caught in a sex-gender system that is nevertheless binary despite its expansion to include trans and non-binary gender identities. Moreover, the bodies of women (and transgender persons) are legislated and treated as the property of others in a way that men’s bodies are not." It's against that background of inequality, she says, that women's choices about their bodies can feel political.
Champagne adds, "Regardless of what a breast cancer patient decides to do with their post-mastectomy chest, their decision may be challenged by others as conforming to sexist or patriarchal conventions or, conversely, stigmatized for disrupting these conventions."
Those are messages Martha got clearly, noting that during her decision-making time, she felt "on display," with even the plastic surgeon "jokingly" asking her husband how big he thought her implants should be. That, along with input from friends, made her body feel not like her own.
"There was this feeling like [choosing implants] was vanity, when for me, I don’t think it was. And even if it was," she says, "mind your own business."