Breast implant lymphoma link

We’re going to examine a very rare link now between cosmetic breast surgery and blood cancer. It’s called anaplastic large cell lymphoma or ALCL. It’s a cancer of the immune system which presents around breast implants. It was discovered by the University of Cambridge’s Suzanne Turner and Chris Smith has been speaking to her…

Suzanne - Some implants have a smooth surface and some have a textured surface, and it's the textured implants which have been associated with this form of cancer. Originally, the very first case was reported in the literature in 1997, so quite some years ago now. But nobody really took much notice of this. This was one case report a very long time ago, and in more recent years it's been discovered that there are more cases and, as the evidence is growing and there are more cases being reported, obviously there is more attention being paid to this.

Chris - What is going on then to link that particular kind of breast implant to this particular kind of rare cancer.

Suzanne - So there are lots of theories hanging around about why this very certain type of breast implant might be driving cancer. Traditionally, we always think of cancer arising when cells in our body pick up lots of mutations, and these mutations can be caused by any number of factors from exposure to the sun, to exposure to different chemicals, and that these cells then just grow out of control. But we are now gradually improving our understanding of how cancer develops in that it's not just down to cells having mutations, but also the environment in which those cells sit. One idea around the breast implant is that there's a lot of inflammation as a result of this foreign body being there in the breast and, over many years, this causes a very chronic and ongoing inflammatory response that eventually allows cells, which may have some mutations, to then grow out and become a cancer.

Chris - I thought that these textured breast implants were the ones being championed as the ones to have because they didn't provoke what got known as capsule formation. The people who had those smooth implants to start with ended up with these very hard, rigid, fibrous tissue in the breast. Very uncomfortable, very unsightly for them, and so everyone shifted to these textured variants. Are they now not the one to have then?

Suzanne - So the textured implants were developed not only to prevent what's called capsular contracture, where you get this thickening of the breast and puckering, and another reason why those textured implants were developed, in some cases, implants are used which have a shape to them: they're not spherical, they're not round, they have more of a pear shape. The idea behind the texturising was that then you would get these fibrous adhesions that would prevent that implant from turning because you don't want a pear shape turning sideways and ending up with a wonky appearance, whereas the round implants could stay smooth because it doesn't matter if a round implant rotates, it's going to be round. What we can say is that in the US the majority market share would be the smooth implants, and in Europe it's the textured implants. Although, having said that, a lot of the textured implants have now been, particularly ones that were developed by a manufacturer called Allergan, removed from sale due to this problem with cancer.

Chris - And what fraction of people who have had one of these textured implants may go on to develop the cancer that you've identified?

Suzanne - There was one particular case study in New York, a very eminent surgeon there who had used the Allergan textured implant for all of his patients, and in his study it's as high as one in a hundred women with textured implants.

Chris - And what does that disease do? Does it just stay local in the breast? Does it spread around the body? Does it behave like any other cancer would? How does it tend to present and then progress?

Suzanne - So the relatively good news is that it is easy to treat, and I say easy with a very heavy heart in that of course women still have to undergo invasive surgery: you have to have the implant removed, you have to have the capsule, this fibrous tissue around it, removed. Then there's also, of course, a very difficult decision as to whether or not you would have it replaced, maybe with a smooth implant or you would just have some other form of constructive surgery. For some of these women, they've also had mastectomies due to breast cancer and now have this second cancer due to their breast implants, so it's a very difficult journey. But survival rates are very high. There have been at least 1600 cases globally. That's probably a huge underestimation. There have been 50 deaths to date. So it can become lethal, and that generally happens if it's not picked up early. The signs to look for are a sudden swelling in one breast, very, very rarely it could happen in both. It may or may not be painful. You may have other symptoms that you would see with patients with breast cancer, so you may feel lumps and bumps. You may not have swelling and just have lumps and bumps. You may have discharge from the nipple, you may have rashes on the skin in that area. So any of these sorts of symptoms that you would regularly look for when you're checking yourself for breast cancer apply in this situation too.

Chris - Have you tracked down what the trigger is? You're saying it's chronic inflammation, but that's not happening for no reason. So what is provoking that in the susceptible person?

Suzanne - So there are a number of theories out there. One idea is that there are potentially chemicals on the surface of the implants and that these chemicals themselves are mutagenic, they can harm your DNA. There are lots of studies which are trying to pin down what these chemicals might be including in my own lab. We have had some success now with detecting some chemicals on the surface of brand new implants. The trick is when you find them, they're not necessarily there when the implant has been in place for 10, 20 years.

Chris - We put textured things in different places in the body in different contexts, though, don't we? We, for instance, do surgeries to repair hernias, we put joint replacements in that have textured surfaces to lock them into bones and so on. Do we have therefore a theoretical risk of this sort of process happening elsewhere?

Suzanne - It's entirely possible. There have been isolated cases reported of cancers associated with other medical devices which have been put in the body. I don't want to scare anybody, it's exceptionally rare that we've seen these cases and there's no evidence, no unequivocal evidence, to associate that that's causative of the cancer. But we are seeing this and I think part of the issue is that, in essence, we become guinea pigs ourselves with medical devices in that the regulations, the regulatory agencies, the government authorities, which decide what sort of tests have to be done to prove a device is safe before it goes into a human body, are woefully inadequate.