What is more cause for alarm, however, is that the risk of breast cancer is up to three times higher in the Bay Area than the rest of California, which already has the highest rate of breast cancer diagnoses in the country.

Dr. Kirk Churukian, a Los Gatos-based plastic surgeon and reconstruction specialist, agrees that the disease has hit Los Gatos, as all other Bay Area towns and cities, relatively hard. And not only are more women being diagnosed but those diagnosed are younger and younger. Although no one has a definitive answer as to why the rate of cancer is so high in the Bay Area, it is clear that breast cancer is a threat to women and even men.

Seven years ago, Patricia Golmon Ball discovered cancer had taken over one of her breasts, with a high probability of the cancer spreading to the other side. Instead of waiting for that to happen, Ball decided to have both breasts removed at once—the operation is known as a double mastectomy.

"Once you get the diagnosis, you feel like you're entering the twilight zone," she says. "But finding that you can get out of it and be even better is amazing. It's about conquering that fear factor."

She believes it is important for recently diagnosed women to become part of a cancer network, as the level of support from survivors is different from that of family members, who either may not know how to react or be overly emotional or stoic. "Some people deal by not dealing," Ball says. "But that doesn't help you at all."

One of the women Ball worked with through the network was San Jose Unified School District kindergarten teacher Celestina Finkle.

On Halloween, Finkle had a mammogram that showed suspicious results. She had a biopsy taken of her left breast and found out she had cancer. It was a very small tumor, roughly 1.5 centimeters in diameter. She talked with her doctor about the type of cancer she had and her options.

"It was just a can of worms you didn't even want to open," she says. "I felt confused, then in disbelief and shock. Then I cried. But I got through all that, and then I thought, 'Now I'm going to attack this thing.' "

Photograph by George Sakkestad Plastic surgeon Dr. Churukian goes over the procedure he is about to perform on Celestina Finkle. She has already been through one surgery, in which her cancer was removed and a tissue expander was put in place. The expander was filled with saline over a period of time, preparing the breast for the permanent implant.

One surgical procedure is a mastectomy, which removes affected breast tissue. It can, according to the American Society of Plastic Surgeons, be "segmental, partial, complete or total." Mastectomies are mainly performed on malignant or premalignant tumors but can be done on benign disease formations.

A lumpectomy is an excision of the cancerous lump along with a small amount of breast tissue surrounding the diseased area. After a lumpectomy, radiation therapy is used for a varied amount of time. According to the ASPS, 20 to 30 percent of patients undergoing lumpectomies will have some type of breast deformity.

Once detected, breast cancer can range from stage one, when the carcinoma is invasive but the tumor is less than an inch in diameter, to stage four, in which the cancer has metastasized and spread tumors throughout the body—including the bones, lungs and brain—and survival rate is relatively poor.

A precursor to stage one cancer is in situ carcinoma, which is when the tumor is completely localized and can be removed at one time. It is sometimes referred to as stage zero because the cancer has not spread at all. Patients with this have a 25 percent chance of developing breast cancer. Malignant tumors can also be found in the fatty and connective tissue of the mammary gland. This is called a sarcoma, and it also has the possibility of metastasizing.

With a mastectomy, there are three choices for reconstructive surgery, Dr. Churukian says. One option is to have a mammary prosthesis (implant), which is then covered by remaining skin after the cancer is removed. If the skin does not have adequate elasticity, a saline tissue expander will be implanted first. The expander is a bag that is periodically filled with saline to slowly stretch the skin and prepare the area for an implant, which could be six weeks to six months—depending on the rate of skin flexibility—after the expander was initially inserted.

Two other options involve regional tissue transfer; these are used when a patient lacks enough skin to hold in an implant. A latissimus dorsi flap operation may be performed, where skin, fat, and muscle are taken from the back and used in the breast. Often an implant is used with this operation.

Another option is for skin, fat and muscle to be taken from the abdomen and transferred to the breast to provide a large amount of tissue. This is known as a TRAM (transverse rectus abdominis musculocutaneous) flap.

Dr. Churukian says a TRAM flap procedure can take between five and eight hours. It is much more involved than other procedures and is not frequently performed by many doctors; however, he does perform the operation. He believes that if this is a possible option for the patient it is optimal because "nothing is as soft or natural-looking as your own tissue." Opting for this surgery also "depends on how much you want to invest in it. TRAM flap surgery typically costs more and is tougher on the body in the short term. You are looking at a five-day hospital stay as opposed to overnight."

After the breast mound surgery is complete and and the area is healed, the plastic surgeon will go back and create a nipple and areola. The nipple is usually created by taking skin from the body and forming it to take the shape of a nipple. The areola is then tattooed on the body. This procedure can be performed up to a year after the initial breast surgery.

Although old, grizzly images of mastectomy scars and concave chests from surgeries loom large in the minds of new cancer patients, technology now allows women to choose from many options that do not leave them disfigured or missing a crucial body part. Reconstructive surgery can be done immediately after the cancer is removed, which Dr. Churukian says provides a benefit because it is "something to fill up the bra right away."

"Reconstruction addresses quality-of-life issues," Dr. Churukian says. "It minimizes the psychological impact of an awful disease. Losing a breast in our society can sometimes be very devastating for a woman. Reconstruction doesn't replace the exact look and feel, but it is surprisingly similar to a real breast and makes the woman look normal."

He says the mental aspects of the process are "the biggest factor in doing well with any disease," and the surgeon's outlook with the reconstruction is "to get people back in their lives and moving forward. It is easy to focus on maladies and afflictions, but you want them to realize that life goes on and you are doing this to take away the distraction and allow them to lead a fulfilling, productive life."

Photograph by George Sakkestad A Good Samaritan Hospital nurse preps Celestina Finkle for her final implant surgery, which will reconstruct her left breast after her previous mastectomy.

Ball recommends talking with several doctors about treatment options and checking out their testimonial book, which every doctor should have. "It is important to be your own advocate and have somebody there for you when you visit. This is your body and your life, and you need to have answers."

Finkle was presented with two options in the end—either have a lumpectomy with six weeks of radiation or a complete mastectomy. For her, having the mastectomy wasn't as radical or aggressive as the radiation. "I just wanted them to take it all out and then no radiation. Reconstruction was the light at the end of the tunnel. I'm grateful because I didn't want to think about it; I wanted it all out at once," she says.

To help make this decision, she brought a tape recorder to every doctor's appointment so she could catch anything she missed while also being able to share the information with her family later on. However, she says, "nobody can tell you what to do. It is your choice. And I knew I didn't want radiation. But you have to quiz the doctors and become knowledgeable." She recommends visiting cancer websites and compiling relevant information before seeing any doctors.

Finkle recently had her permanent implant put in after weeks of having a saline tissue expander in place. She initially chose saline for her implants due to health concerns but close to surgery changed her mind and decided to have silicone, which would provide a more natural shape and last longer—saline implants need to be changed about every 10 years. She also had a lift done to her right breast to match the newly reconstructed breast. Just prior to her final implant surgery, Finkle was back to walking to school every day and had full use of the arm where two lymph nodes had been removed.

Ball has had two reconstructive surgeries. Her first, a saline implant done by a surgeon other than Dr. Churukian, did not go well. She "had a terrible time" afterwards, was constantly in pain and was scarred.

Ball decided to take action. She decided to have another surgery, this time with Dr. Churukian, and use silicone implants. "I wanted to feel as natural as I could," she says of her choice to use silicone, which is now only offered to breast reconstruction patients. "Now they feel part of me, and I don't think of them as something different."

Ball is proud of her chest and what it symbolizes—healing, strength and perseverance. "It doesn't even look fake. It is truly wonderful and incredible. Having been through cancer, I feel better than ever," she says. "I am more active and feel better about myself. I feel healthier."

She has been cancer-free since the surgery and now sees her oncologist—a cancer specialist—once a year. When first beginning treatment, a patient must see her oncologist every three months, then every six months, then twice a year and eventually once a year.

Two years ago, Ball started her own interior and exterior design business. She is thrilled about her new work and the opportunities it affords her to be creative and meet people. She is also more physically active than she has ever been and maintains a healthy diet. Interestingly enough, Ball thanks cancer for enabling her to step up to these challenges and meet them with a lighthearted spirit.

"People that handle it the best keep their sense of humor. Think of it as an adventure, not a trauma to your life," she says. "My life changed dramatically for the better. You look at things differently and embrace that."

"We don't have a choice of what happens to us, but we do have choices in how to deal with it and how we feel about it," she adds. "It's a wake-up call to look at your life, regardless of the outcome. Women are scared to death to lose their breasts, but it doesn't have to be the end of your life. You can't run away from it, but you can take it as it comes."

Since her diagnosis, Finkle has become involved in local cancer networks and formed friendships with two other co-teachers who have had breast cancer. Finkle says one of the most amazing outcomes of the cancer and reconstruction process is being able to help new patients.

"One of the teachers was just diagnosed and I was able to clue her in," she says. "My heart warmed just by helping her. Helping has been fantastic for both of us."

Although Finkle still has more healing to do before she is fully back in the swing of things, she has a hearty sense of optimism. "I'm a survivalist. I've always looked at a task, looked at my goal and then shot for it," she says. "You get over the emotions and say, 'What is my plan now?' I didn't have the answers the whole time, but I always wanted to attack it head-on."

Law requires that insurance pay for 'balancing surgery'

When reconstructive surgery is done on an affected breast, insurance companies are required to not only pay for reconstructive surgery but to cover a "balancing surgery" on the healthy breast, which may include a breast lift (mastopexy), augmentation mammaplasty (enlargement surgery) or reduction mammaplasty.

The Women's Health and Cancer Rights Act of 1998 states: "The attending physician and patient are to be consulted in determining the appropriate type of surgery. Coverage must include all stages of reconstruction of the diseased breast, procedures to restore and achieve symmetry on the opposite breast and the cost of prostheses and complications of mastectomy, including lymphedema."

Reconstruction can be performed immediately after the cancer surgery or can be done weeks or years afterward. The only restriction is if a patient is receiving radiation, according to Dr. Kirk Churukian. "Radiated tissue doesn't do well with an implant. There is a higher chance of infection and breakage." If a patient has had radiation prior to reconstruction, the only option is to use the patient's own tissue. However, if radiation is needed after reconstruction, a patient with implants can undergo treatment.

He also recommends a patient wait three to six months after finishing chemotherapy for getting implants.

Measures for detecting breast cancer are essential to catching cancer early on, which provides a better chance for beating it. Annual mammograms are recommended for women over 40. A clinical breast exam is recommend every three years for women 20 to 39 years old and once a year after 39. A monthly self-exam is recommended for women 20 years old and up.