Sir:
We were interested to read the latest update on the risk estimate of breast implant–associated (BIA) anaplastic large cell lymphoma (ALCL) by Collett et al.1 They highlight the importance of better implant texturing classification (by roughness and surface area) with the greatest (grade 4) having a BIA-ALCL lifetime risk of 1:2832. In the Netherlands, de Boer et al.2 calculated a 1:6920 risk of BIA-ALCL, but despite the quality of their epidemiological study, they could not find a statistically significant association by implant type or texture. We agree with the authors that there has been much variation in BIA-ALCL risk estimation and there is a need for effective and mandatory national implant registries to aid safety research and quality monitoring.
Unsurprisingly the lay media have not helped put BIA-ALCL risks into any real perspective, and some authorities have recently rushed to ban several implant types. Many surgeons have been debating converting all their breast implants from textured to smooth, from silicone to saline filled, from older to newer devices without any long-term track record (good or bad), regardless of evidence this might have risks, including increased capsular contractures and reoperation rates. The United Kingdom’s Royal College of Anaesthetists estimate a healthy adult receiving a routine general anesthetic has a risk of death of 1:100,000, and 1:10,000 will experience anaphylaxis.3
Whilst rightly informing patients and educating clinicians of risks, particularly in those considering reconstruction in the breast cancer setting, the ‘elephant in the room’ is that breast implants are known to obscure mammographic screening for breast cancer, the most common cancer that one in eight women will suffer from in their lifetime. Despite extra displacement views, some estimate a reduction from 95 percent to only 85 percent of the breast tissue can be assessed.4 Putting this reduction in sensitivity/accuracy in a national context, for the United Kingdom program that detects eight cancers per 1000 women screened, it means potentially missing 1684 cancers in the 2 million women per annum screened.
Everything has a risk. Putting this in practical context, Cancer Research UK quotes the radiation from 3-yearly mammography between the ages of 47 and 73 will cause an extra breast cancer in 1:2222 women screened (higher than the highest risk estimates of BIA-ALCL). Public Health England quotes a risk of 1:49,000 to 1:98,000 of radiation-induced cancer from a single screening mammogram5 (equivalent numeric risk levels to lower texture-grade implants); in fact radiation risks would be even higher in women with implants who require double the number of views.
Collett et al. remind us that only 45 cases of ALCL have ever been reported in the United Kingdom, with only one death directly attributable to this rare disease, which is easily treatable in 75 percent of cases by explantation and capsulectomy only. Risk is challenging to estimate, perhaps more so to comprehend or communicate, but we urge leadership by balanced reporting in context by our academic journals.
DISCLOSURE
None of the authors has any financial interests to disclose.
Yezen Sheena, F.R.C.S.(Plast.)
Breast Surgery Unit
Broomfield Hospital
St. Andrew’s Centre for Plastic Surgery
Broomfield Hospital
Chelmsford, United Kingdom
Simon Smith, F.R.C.S.(Eng.)
Sacha Dua, F.R.C.S.(Eng.)
Breast Surgery Unit
Broomfield Hospital
Chelmsford, United Kingdom
Mary Morgan, F.R.C.S.(Plast.)
St. Andrew’s Centre for Plastic Surgery
Broomfield Hospital
Chelmsford, United Kingdom
Venkat Ramakrishnan, F.R.C.S.(Plast.)
St. Andrew’s Centre for Plastic Surgery
Broomfield Hospital
Anglia Ruskin University Medical School
Chelmsford, United Kingdom
REFERENCES
1. Collett DJ, Rakhorst H, Lennox P, Magnusson M, Cooter R, Deva AK. Current risk estimate of breast implant-associated anaplastic large cell lymphoma in textured breast implants. Plast Reconstr Surg. 2019;1433S30S–40S.
2. de Boer M, van Leeuwen FE, Hauptmann M, et al. Breast implants and the risk of anaplastic large-cell lymphoma in the breast. JAMA Oncol. 2018;4:335–341.
3. Royal College of Anaesthetists. PAGE TITLE HERE. Available at:
https://www.rcoa.ac.uk/sites/default/files/documents/2019-08/Risk-infographics_2019web.pdf. Accessed January 11, 2020.
4. Miglioretti DL, Rutter CM, Geller BM, et al. Effect of breast augmentation on the accuracy of mammography and cancer characteristics. JAMA 2004;291:442–450.
5. Public Health England. Radiation risk with digital mammography in breast screening. October 23, 2017. Public Health England, Available at:
https://www.gov.uk/government/publications/breast-screening-radiation-risk-with-digital-mammography/radiation-risk-with-digital-mammography-in-breast-screening. Accessed January 11, 2020.
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