Good Thursday morning! This Breast Cancer Awareness month, we're bringing you a special edition from our colleague Carly Mallenbaum.

☀️ Today is sunny with highs in the low 80s.

Today's newsletter is 907 words, a 3.5-minute read.

For years, patients have had to navigate a maze of conflicting mammogram advice. Now, artificial intelligence could help cut through the noise.

• "Using AI to develop individualized screening schedules rather than one-size-fits-all recommendations" is where the field is heading, says J. Pierre Sasson, the department chair of radiology at Mount Auburn Hospital and assistant professor of radiology at Harvard Medical School.

The big picture: By analyzing thousands of mammograms and patient outcomes, new AI tools can help doctors better identify who's at highest risk — and when they should be screened.

Zoom in: Mirai, Transpara, ProFound and Clairity Breast are emerging AI tools that use mammogram images to assess patient cancer risk.

Between the lines: Major health organizations still differ on when women at average risk should get screened.

• American Cancer Society: Annual screening is optional for ages 40–44; recommended for ages 45–54; every 1–2 years for ages 55+.
• American College of Radiology: Annual mammograms starting at 40.
• U.S. Preventive Services Task Force: Mammograms every other year for women ages 40–74.

And in addition to mammograms, there are other available screening tests, including ultrasound and CEM, often useful for patients with dense breasts.

The latest: Sasson tells Axios that AI is already integrated into his hospital's workflow. For example, it flags suspicious areas on mammograms.

Yes, but: "The human connection — compassion, reassurance and judgment — is still the heart of medicine," he says.

What we're watching: AI is also driving cancer screening efforts outside of the standard mammogram: Tech startup SpotItEarly hopes to use it to track disease-sniffing dogs, and determine if they have subtle behaviors that could signal the presence of cancer in a patient's breath.

A wave of new state laws is making fertility preservation procedures a covered benefit for cancer patients.

Why it matters: Chemotherapy and radiation can cause reproductive problems, but procedures like egg freezing and emerging technology such as ovarian tissue freezing are costly and can be left out of cancer treatment conversations.

• As more Americans survive cancer at younger ages and delay parenthood, demand increases for these kinds of treatments.

By the numbers: 21 states and Washington, D.C., now require insurers to cover fertility preservation for medical reasons, per the Alliance for Fertility Preservation.

• There was legislative action this year in Georgia, Virginia and New York, and executive director Joyce Reinecke tells Axios she's "hopeful" that laws are passed in Hawai'i and Washington next.

Between the lines: Coverage rules vary by state, including which insurers must comply, which procedures are included, and which diagnoses qualify patients for coverage.

• "Experimental" procedures, such as uterine displacement and in vitro maturation, are rarely covered by insurance.

More breast cancer survivors are choosing not to reconstruct their chests after mastectomy and going flat instead.

Why it matters: The shift reflects a cultural change in how survivors define recovery, beauty and body autonomy.

State of play: "In years past, the assumption was you were gonna have a reconstruction," says Mary Gemignani, chief of breast surgery at NYU Langone Perlmutter Cancer Center.

• Now, there's a movement highlighting that it's OK not to have one, and patients increasingly ask for "flat aesthetic closure," she says.
• That's the term — promoted by breast cancer survivor advocacy groups like Not Putting on a Shirt (NPOAS) — for a flat chest with no excess skin after surgery.

Between the lines: Data suggests that most patients who get a mastectomy go flat, with more young people intentionally choosing that option in recent years for a faster recovery and to avoid getting tissue expanders or implants.

The big picture: As celebrities remove implants and dissolve fillers, "there's a trend toward embracing your natural body," says Kim Bowles, president and founder of NPOAS.

• Even in the breast augmentation space, women are choosing smaller breasts.

Zoom in: Bowles, a breast cancer survivor who had a double mastectomy, said reconstruction didn't appeal to her — even though she was a candidate for DIEP flap surgery, which uses belly tissue to build new breasts.

• Going flat allowed her to avoid a major surgery and embrace the "freedom" of being bra-less. (But flat bras are also a thing.)
• When she first asked to go flat, however, her surgeon ignored the request and left extra chest tissue. She now works to prevent what she calls "flat denial" — when surgeons disregard patient preferences.

What she's saying: "Just because you lost a couple of bags of tissue on your chest, it doesn't make you less of a woman."

Imagine a Day Without Water highlights how essential water is in our day-to-day lives.

The details: Beaver Water District is collaborating with local businesses to emphasize the importance of safe, clean drinking water and its role in NWA communities.

Watch to learn more.

Fifteen years ago, tattoo artist Amy Black got an unusual request: Could she ink a realistic-looking nipple?

Why it matters: That question came from a breast cancer survivor who'd undergone reconstruction. The answer was yes, and the results were life-changing — both for the client who loved the tattoo and also for Black.

• She built a new specialty in mastectomy tattoos.

The big picture: Black's mastectomy ink "used to be 90% nipple tattoos," but now she sees an increasing number of survivor requests for decorative art, often on flat chests.

What we're hearing: Planning a tattoo post-surgery felt like "getting the last word on the way my body looks," breast cancer survivor Kim Bowles tells Axios.

See the tattoos

Imagine a Day Without Water highlights how essential water is in our day-to-day lives.

What you need to know: This year, Beaver Water District is collaborating with local businesses to emphasize the importance of safe, clean drinking water and its role in NWA's economy.

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