BREAST IMPLANTS AND CANCER; WHAT YOU NEED TO KNOW
By Dr. Lane Smith, F.A.A.C.S., F.A.O.H.N.S., F.A.B.F.P.R.S.
For many years it was widely assumed and taught that breast implants did not increase the risk of cancer. However, this is now known not to be completely accurate. Recently the FDA, in cooperation with breast implant manufacturers, and medical societies such as the American Society of Plastic Surgeons, released a statement regarding the risks of a specific type of cancer that is associated with breast implants. This cancer is called breast implant-associated anaplastic large cell lymphoma, which is abbreviated BIA-ALCL. To be clear, this is not a type of breast cancer, it is a type of lymphoma. Lymphomas are cancers that arise in the lymphocytes which are the cells in the body that help fight infection. These cancers can arise when serous fluid or excessive scar tissue, called capsular contracture, forms around breast implants. Luckily, this type of cancer is usually easily treatable by removing the breast implants and the surrounding scar tissue.
While the FDA noted an association between breast implants and cancer, the FDA stopped short of recommending their removal. The benefits of breast augmentation have been proven in many studies. Breasts are strongly associated with femininity and breast augmentation has been shown to have many positive benefits including increased self-esteem, increased confidence, lower incidence of depression and a general improvement in lifestyle and happiness. The patient satisfaction rate after a successful well-performed breast augmentation is well above 90%. Therefore, in this case, the benefits generally outweigh the risks provided a few guidelines are followed.
In 1996, the first reported case of this rare type of lymphoma, Anaplastic Large Cell Lymphoma (ALCL) was found arising in the scar tissue surrounding a breast implant. Over the ensuing years, a number of these cases began to be reported. Because these occurrences were rare, it took until approximately 2011 for the medical community to begin to notice that there may be an association between breast implants and ALCL. Fortunately, this cancer is uncommon and as of March 18th, 2019 only 270 cases of BIA-ALCL have occurred in the United States and approximately 688 worldwide. This is relatively rare as there are literally millions of women worldwide who have breast implants. In the United States alone, there are approximately 300,000 breast implants placed in women each year for cosmetic reasons and approximately another 100,000 breast implants that are placed for reconstructive purposes (eg. after breast cancer, etc.).
To understand your risk of developing BIA-ALCL, it is important to know something about breast implants. Breast implants have an outer silicone shell and an inner silicone matrix or gel. Some implants are filled with saline (saltwater), instead of a silicone gel, but the outer shells are basically the same. The shell can be “smooth” or “textured.” Just as the name implies, the outer shell can have a smooth surface or a rough-textured surface. Textured implants are thought to have a lower incidence of capsular contracture and hold their shape slightly better. They are known to have a greater incidence of seroma or fluid build-up around the implant.
Smooth implants tend to feel more natural and ripple less. The implant manufacturers specifically treat the shells to make them rough and textured and it is this treatment that is postulated to be a possible cause of the cancer. In my practice, I used smooth implants 99% of the time because I think they look and feel more natural than the textured implants. Most, if not all, of the cancers occurred in women with textured implants. It is debatable if any of the cancers occurred in women with “smooth” or non-textured implants. Therefore, women with smooth implants probably do not need to worry about BIA-ALCL and women with textured implants have a lifetime risk of this cancer occurring which is estimated to be between 1:3800 to 1:30,000.
The presence of textured implants alone is probably not enough to cause BIA-ALCL. Usually, an additional occurrence such as capsular contracture or fluid around the implant (seroma,) must also be present. All implants form some scar tissue around them. The body does this to “wall off” the foreign body (breast implant) from the surrounding natural tissue. Most of the time, the patient cannot feel or see the effects of this scar tissue. Breast implants can be placed under the breast tissue itself or under the pectoralis muscle which sits directly below the breast tissue. Approximately 3% to 9% of patients who have breast implants under the pectoralis muscle called submuscular placement and up to 24% of patients who have breast implants on top of the pectoralis muscle, called subglandular placement, will develop extra scar tissue which can make the breast implants feel very hard and firm and give them a very round and fake appearance. When this occurs, it is called capsular contracture. Another possible side effect of breast implantation is the accumulation of serous fluid around the implant. This fluid is similar to the fluid one would find in a blister. When this occurs, it is called a seroma.
While there may be exceptions, in almost every case, in order to get BIA-ALCL, a patient must have a textured implant and the presence of either capsular contracture or a seroma. This is because the cancer develops in the scar tissue or the fluid surrounding the implant and not on the implant or in the breast or muscle on top of the implant.
What steps should a patient take who has breast implants? First of all; all women, whether they have breast implants or not, should perform monthly self-breast exams to screen for breast cancer. While some studies have not shown this to be helpful, from my experience I believe it is helpful. If a lump in the breast or armpit area is found, or unusual breast tenderness is noted, or if there is a change in the skin texture over the breast or around the nipple, or change in the shape of the breast itself, the patient should see their physician. While this is controversial, most physicians believe patients should have a screening mammogram at approximately age 40 or if there is a strong family history of breast cancer, at age 35. If a woman has a very strong family history of breast or ovarian cancer occurring at a young age, they should probably be tested for the BRACA 1 and BRACA 2 genes.
Depending on risk factors, patients should continue to have screening radiography every year or two after age 40 and every two years after age 55. If a woman has a smooth breast implant this is probably all the screening that is necessary.
If a woman has a textured implant, then they need to perform all of the screening listed above and notify their physician immediately if any of the above-listed signs or symptoms occur. They should also watch for a few additional things such as late-onset capsular contracture, enlargement of the breasts due to fluid (seroma), and any change in the shape of the breasts. I would recommend that any woman with a textured implant who also develops a capsular contracture or seroma see their plastic surgeon for evaluation. Although this has not yet been recommended by the FDA or Plastic Surgery Society, I personally would recommend that any patient with textured implants and capsular contracture or seroma undergo surgery to have the textured implants and scar tissue removed prophylactically. Patients who have textured implants and no seroma or capsular contracture probably do fine without surgery or removal of their implants as long as they perform their monthly self-breast exam.
In my practice of performing over 4500 breast augmentations, which is among the most in the United States, I have clearly seen the positive effects that breast augmentation can have in a woman’s life. I will continue to perform breast implantation surgery and I highly recommend it for women who feel self-conscious about their breasts.
In my personal practice at Smith Plastic Surgery, I rarely used textured breast implants; however; from this moment forward I have decided to eliminate them from my practice. When “smooth” breast implants are used the risk of BIA-ALCL may be non-existent or at very least, extremely rare.
In conclusion, it is important to remember that breast augmentation is a relatively safe surgery with a very high satisfaction rate that can positively impact a woman’s quality of life.
Lane F. Smith, M.D.
F.A.A.C.S., F.A.O.H.N.S., F.A.B.F.P.R.S.
For More Information on Dr. Lane Smith and Smith Plastic Surgery please contact:
Smith Plastic Surgery
7650 West Sahara Avenue
Las Vegas, Nevada 89117