Cosmetics linked to cancer

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.

According to Cancer Research UK, skin cancer rates are at an all time high, with around nine in ten cases caused by exposure to too much UV radiation from the sun and sunbeds. In fact, of the 21,000 cases of skin cancer in the UK this year it’s thought that 17,000 of them were preventable. It was with this in mind that people under the age of 18 in the UK were forbidden from using tanning beds in 2011 - but it’s believed that around a quarter of adults in the UK still do. There are also concerns that UV lamps used in nail salons can kill cells and that they could be linked with cancer. So, could our thirst for golden tans and immaculate manicures be putting us at real risk of serious illness? Speaking on the subject is dermatologist, Jane Sterling…

Jane - Every time you go out into the sun, the ultraviolet light affects the cells, the building blocks, of the skin and produces some damage to the DNA, the genetic messenger if you like, in the skin. Our skin usually repairs that damage quite well, but in doing so, you can get sunburn and sometimes that repair doesn't work quite right, nothing's perfect. And over the years, every time you get a little bit of not completely repaired DNA damage, those are kept in the skin and gradually they reach a threshold when a lot of little bits of damage can tip you over into getting skin cancer.

Chris - And which cells does that affect?

Jane - Well that can affect the melanocytes, those pigment producing cells and can also affect the surface epidermal cells. They're called keratinocytes and they can cause a different sort of skin cancer to the melanoma type skin cancer that arises from melanocyte damage.

Chris - And what should someone look out for? What might be the danger signs?

Jane - So melanomas usually appear as an enlarging dark, brownish black spot on the skin. And if something like that starts to appear and grow in a site where there's never been a mole before or where there's been a small mole, then see your doctor as a matter of urgency. And squamous cell cancers usually tip up a bit later in life as a rough raised bump. So they're a little bit more difficult to spot perhaps, but something appearing where there hasn't been anything before should also be looked at.

Chris - And is the mechanism you just described the same regardless of where I get the ultraviolet, whether I'm out there on a sunny day, or on the beach, or I go to a sun tanning parlour?

Jane - It's pretty well exactly the same. The doses, depending on how long you stay out in the sun or on the sun bed may be different, but the mechanism is exactly the same.

Chris - We know that sun exposure is linked to skin cancer and skin ageing, but is there evidence that sun tanning parlours are equivalently linked to skin cancer?

Jane - Yes, there is. People have looked back at people who've developed skin cancers at various points in their life and asked of course, how much sun exposure have you had over life? Have you lived abroad in very sunny places? Have you been a sun worshipper going on lots of sunny Mediterranean holidays, for instance? Or have you used sunbeds? And there are links with all of those to an increased risk of skin cancer. So people who've lived abroad in Africa or Australia, people who've loved to sunbathe and have had two or three Mediterranean holidays a year and people who have been regular users of sunbeds, all of those have a higher risk of getting skin cancer. Let's break that down into a sort of theoretical group of a hundred people aged 50 with skin cancer. A good proportion of those, I'm guessing now, but I would think that a good 50% of those would be able to say, well yes, I have had a lot of sun over my life. So you really want to get only a mild tan. And particularly that applies if you have the sort of genetic makeup that makes you even more prone to skin cancers. So that would be people with fair skin who burn easily. That's people with blonde or red hair, people with lots of freckles, people who have lots of moles and very, very important, and I think lots of parents are aware of this now, is that if you get a lot of sun exposure at a young age, that's even worse than getting it later in life.

Chris - What about other places where we use UV, both therapeutically and cosmetically. For instance, dentists use it. Also nail bars fuse certain nail accoutrements on fixed glues with ultraviolet exposure. So does that mean that there's a theoretical risk in those settings, both to the person who's being zapped with the UV, but also the person who's using the UV professionally to do those services?

Jane - Well, that's a good question and I can only give you a theoretical answer. Hopefully people don't have too many fillings, but people do sometimes go quite regularly to nail bars and quite regularly have that sort of ultraviolet light exposure. The nail bar workers should be protected against that because the nails are put under a little box-like thing that shouldn't allow the ultraviolet radiation to come out directly onto the people, but they need to be careful. But of course the intensity of it is on the nails themselves. I suppose it's perhaps in the last 10 years, I don't know really, that people have started to go to nail bars very regularly. Sometimes once a week or once a month. And this exposure to ultraviolet really wasn't thought about as being a particular risk, but it is now known that the damage that occurs to DNA that we see with going out in the sun can happen with the ultraviolet light used in nail bars.

Chris - If someone listening to this has had a lot of exposure, they may now be worried. And what can they do to minimise the risk of there being a problem?

Jane - I'm going to sound like an old fogey here, but I think that minimising the risk is not to do it. So sunbeds, I can't think of any reason really why people should want to do it as now there are such good creams that can be used to give a brownish appearance to the skin. They're very good. Nails, it's not essential to have gel nails. You can have beautiful nails in other ways, in my opinion. But for both of those, if the desire to have frequent treatments is excessive and unavoidable, then please keep it to a minimum. Is all I can say. I mean, a few episodes a year is probably okay, but regular use is probably not.