The most common cancer found in the breast by far is primary breast cancer. This is cancer that originates in the ducts or glands of the breasts. It commonly presents as a mass in the breast and is what we screen for with self-examination, mammograms, ultrasound, MRI and other modalities of breast imaging. If a woman lives to 80, she has a one in eight chance of developing breast cancer.
If you have a strong family history of breast cancer, you have a higher chance of developing breast cancer. The opposite is true for a negative family history; however, 80% of all breast cancer patients do not have a family history of breast cancer.
It is important to differentiate that primary breast cancers originate in the breast tissue proper, and are not associated with the presence of breast implants. In other words, primary breast cancers occur at the same rate with or without breast implants.
Breast Implant Associated Breast Cancers
Breast Implants remain the safest and most predictable method for breast augmentation; however, several rare tumors have been associated with their use.
Over the last 20 years, there has been an increased awareness of breast implant associated tumors. These are extremely rare, but they are real. Their occurrence is so rare that a causative relationship has yet to be demonstrated. Proposed mechanisms have included everything from an aggressive inflammatory response to bacterial contamination. While all good working theories, nothing is proven to date.
BIA-ALCL
The most studied of the breast implant associated tumors is the anaplastic large cell lymphoma (BIA-ALCL). This is a rare tumor that tends to have a better prognosis than ALCL that is not associated with a breast implant. Despite an all out push from the world’s national and international plastic surgery societies to collect the data, there have not been enough cases to prove a direct link.
There seems to be a genetic contribution among women with European heritage. We know that BIA-ALCL is more commonly found around textured implants. While the vast majority of breast implants used in the US, Europe and Australia are smooth, the majority of patients presenting with BIA-ALCL in these countries have textured implants. Asian countries use more textured breast implants; however, BIA-ALCL is less common in Asian patients. I cannot stress enough that we are talking about only a few cases, so these trends may change as more data is collected. In addition, a significant number of these patients are breast reconstruction patients who have been treated with immune modifying drugs for a previous breast cancer.
BIA-ALCL can present as a mass, but more commonly presents as a collection of fluid around the breast implant. BIA-ALCL usually presents years after the initial breast augmentation and frequently presents as a significant enlargement of the affected breast.
Diagnosis consists of sampling the fluid around the implant and looking for the lymphoma cells. When caught early, the treatment consists of removing the implant and the capsule for cure. When the tumor involves the chest wall, additional treatment is recommended.
Other Breast Implant Associated Tumors
In the quest to identify every tumor near a breast implant, a few other tumors have been found around breast implants. These are even more rare than BIA-ALCL. Only a handful of cases have been identified. On September 8, 2022, the FDA released a Safety Communication. Fewer than 20 cases of Squamous Cell Carcinoma (SCC) and fewer than 30 cases of lymphomas other than BIA-ALCL have also been identified.
How Rare are These Tumors?
If you have one of these tumors you have it 100%, and I do not want to give the impression that the low probability of getting these tumors diminishes the significance of the diagnosis. On the other hand, it is important to provide some perspective to the risk.
The FDA has been collecting this type of data since 2011. In that time, 20 cases of BIA-SCC and 30 cases of BIA-nonALCL have been identified. About 1000 cases of BIA-ALCL have been identified. During that same time about 3 million women were diagnosed with primary breast cancer and about half a million died of the disease.
Breast Cancer Diagnosis and Treatment
I applaud the FDA’s dogged surveillance of breast implant safety. We are all on the side of saving lives and reducing suffering. Moreover, as a plastic surgeon, I want to supply safe treatments for my patients needing breast reconstruction and augmentation.
At the same time I am appalled by the USPSTF recommendations for delaying mammography until age 50. There are many large studies that confirm 40 as the best balance between preventing cancer deaths and the injury from over surveillance. Delaying screening until 50 leads to greater mortality. This is especially true in populations that tend to have breast cancer earlier in life and more aggressive tumors.
Breast Cancer in Hispanic Women
Breast cancers tend to present at younger ages and more aggressively in Hispanic women, according to the Breast Cancer Research Foundation.
Breast Cancer in Black Women
According to Komen.org among younger women, Black and non-Hispanic Black women have higher rates of breast cancer compared to white and non-Hispanic white women. In addition, black women tend to have more aggressive tumors and tend to get diagnosed at later stages of the disease.
Delayed screening will affect these populations disproportionately. The best way to cure cancer is to diagnose it early and remove it before it spreads. The American College of Obstetrics and Gynecology put in best in their Practice Bulletin on Breast Cancer Risk Assessment and Screening in Average-Risk Women.
- For women in their 40s, the number who benefit from starting regular screening mammography is smaller and the number experiencing harm is larger compared with older women. For women in their 40s, the benefit still outweighs the harms, but to a smaller degree; this balance may therefore be more subject to individual values and preferences than it is in older women. Women in their 40s must weigh a very important but infrequent benefit (reduction in breast cancer deaths) against a group of meaningful and more common harms (overdiagnosis and overtreatment, unnecessary and sometimes invasive follow-up testing and psychological harms associated with false-positive test results, and false reassurance from false-negative test results). Women who value the possible benefit of screening mammography more than they value avoiding its harms can make an informed decision to begin screening.
Having this choice is very important, and when the government recommends later screening, insurance companies stop paying for it. This makes the choice much harder, especially for those dependent on insurance reimbursement for their care.
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