Cancer risk and breast implants

More extreme than wearing makeup is resorting to surgery to alter your appearance. And one currently very popular body modification is breast augmentation. This involves inserting bread-roll-shaped implants filled either with a silicone gel or a saline solution underneath the breast tissue to make the breasts look larger. People say that it gives them more confidence and satisfaction with their body. But, the procedure has since been linked with an increased risk of developing a cancer of white blood cells called anaplastic large cell lymphoma or ALCL. Chris Smith spoke to Cambridge University’s Suzanne Turner - one of the team that discovered this. First, Chris asked Suzanne how common breast implant surgery is...

Suzanne - About 6 to 10 million per year.

Chris - Oh, huge numbers.

Suzanne - Huge numbers, yeah.

Chris - Okay. And this condition, how did it first come to light?

Suzanne - The first case was reported back in 1997 now. And this was a case that was in the literature but not much attention was paid to it to begin with.

Chris - Tell us about the disease then. When someone has ALCL what have they got? How would they know they had it?

Suzanne - It’s generally a sudden swelling normally in just one breast, which can come on anything from one year to over ten years past surgery. That swelling tends to stay around; it can also come as a lump either in the capsule that forms around the breast implant. This is an area of fibrous tissue that forms in response to the breast implant and lumps and bumps around that area can also be a sign of ARCL.

Chris - Is it painful or painless?

Suzanne - Both. Women have reported all sorts of ranging symptoms associated with this.

Chris - Interesting. So the disease actually happens locally to the implants happening but one side, both sides?

Suzanne - Generally one side. Generally there’s just one side involved.

Chris - So what do we think the mechanism is then that encourages this particular tumour to form?

Suzanne - There are a number of theories out there. The first one that it’s infection driving this so during the surgery perhaps some infection gets involved, and this lingering infection leads to the white blood cells proliferating out of control and becoming this lymphoproliferation - this cancer.

Another theory is suggesting that some women may be allergic to these breast implants and this allergic response, which goes on for a long period of time, again drives these cells into proliferation.

An alternative theory is that for some women there may be an autoimmune condition that predisposes them. So it may be the case that they already have an autoimmunity  and the presence of the implants upsets the balance of white blood cells within their body.

And, of course, the theory we can’t really discount is the breast implants themselves. And are there toxins related to those breast implants, for example, which may also be driving this form of disease? And, of course, we know for many cancers there could, in some cases, be a driving toxic stimuli.

And, of course, breast implants are made of a whole array of different chemicals that we don’t really know too much about. How these are manufactured is a closely guarded secret by the companies that make them.

And so I think all four theories aren’t necessarily mutually exclusive. I think that there may be a multitude of mechanisms towards this particular cancer and that for some women they may be at a higher risk than others due to predisposing conditions.

What we do know is it’s mostly associated with women who have a form of implant that has a textured surface. This is a very specific type of implant that’s been introduced as a way to deal with something called capsular contracture, and this is where the fibrous capsule that forms around the breast implant can pull the skin in forming a sort of dimpling effect. So these textured implants have certainly been more commonly associated with this form of cancer.

Chris - The thing is though, we put lots of other implants into the body. People have hip replacements, other joint replacements and other things put into various places. Do they carry the same risk because many of the mechanisms you’ve outlined do not strike me as being unique to what we do with breast implantation and breast augmentation surgery?

Suzanne - Absolutely. You’re right there so you would expect that if it’s bacterially driven and it’s due to the surgical procedure in itself, you would see these lymphomas occurring in people with all sorts of other implants, and actually you don’t. There are some rare cancers that have been associated with metallic implants but, for the most part, we only see breast implant associated ALCL with breast implants so I think that gives us some clues as to what’s really driving this.

Chris - And just very briefly, what’s your overall risk then? Because there may well be people listening to this if they’re one of that, you know, very large cohort - millions of cases a year having breast augmentation, what’s your risk of having this condition?

Suzanne - It is rare. But the risk in the UK is currently placed at 1 in 28 thousand women with breast implants and that’s data based on the number of implants that are sold, although of course, we don’t know how many of those implants actually make it into women. Although, if you read through the literature the rates of this disease developing range from 1 in 3 thousand women with a textured implant to 1 in 30 thousand women. So there’s a whole array of different rates depending on where you live and which literature you read.

Chris - So if you’re in one of those unlucky groups who is diagnosed with this, Suzanne, what can you do about it?

Suzanne - The treatment is fairly straightforward for the ladies that are diagnosed very early on in the disease. The treatment is literally the removal of the breast implant and the capsule that surrounds the implant and, for the majority of these women, that’s enough to put the disease into remission.

However, having said that obviously it is a surgical procedure and it’s not something that anybody would enter into lightly. And, at the same time, there are the implications of whether or not to have a replacement implant and whether or not that is safe and, unfortunately, we still don’t really know. Some women are having smooth implants put in in place of the textured implants, but I don’t think that the evidence is fully out there yet that the smooth implants are any safer necessarily.

Unfortunately, for some women, these cancers do develop and they do progress into something more, and for some rare women, this can be the first sign of the cancer. I’m aware of ladies who’ve had masses growing into their rib cages with a very aggressive disease that needs chemotherapy.

So it can be a very aggressive, nasty disease and there have been about 16 deaths reported worldwide, so it’s not something which should be looked upon too lightly.

Chris - Do you think on the balance of it that, actually, the ends justify the means? Do you think we should still be allowing people to have breast implants given that they are effectively taking a risk? It’s not just a one in a million chance, these numbers are quite high the risk that you’ve been saying of this happening. 

Suzanne - It’s very much a personal choice, and I think at the heart of it all is that women should be able to make an informed decision. And up until a few years ago that was not the case, women were not being told this was a risk. So now that we do know that it is a risk, it’s very important that plastic surgeons convey this risk to the ladies before they make the decision as to whether or not to have implants.