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Dr. Jones: Do women with breast implants have a higher risk of cancer? What cancer? What's the risk and what should we know?

Announcer: Covering all aspects of women's health, this is The Seven Domains of Women's Health with Dr. Kirtly Jones on The Scope.

Dr. Jones: There are about 300,000 breast implant surgeries performed every year in the U.S. Now, there are a number of reasons for breast implant surgery, but all people requesting breast implant surgery have concerns about risks and side effects. There's a new concern about a very rare cancer that might be more common in women with breast implants.

And today in The Scope studio, we're talking with Dr. Jay Agarwal, who is chief of Plastic Surgery at the University of Utah. He's a plastic surgeon at the Huntsman Cancer Institute, who specializes in breast reconstructive surgery, and he's going to help us think about this risk.

Welcome back to The Scope, Dr. Agarwal.

Dr. Agarwal: Thank you. Thank you for having me.

Dr. Jones: So what did the FDA identify as a possible association between breast implants and a rare non-breast cancer?

Dr. Agarwal: Over the past decade and a half, the FDA, the medical societies, and doctors in general have been paying very close attention to the outcomes of their patients that have had breast implants placed. And so, over the past number of years, we found that there is a very small but significant incidence of a rare lymphoma, and it appears that it's associated with a specific type of breast implant, whether they're placed for reconstructive purposes or cosmetic reasons. And that's ALCL, an anaplastic large cell lymphoma.

Dr. Jones: That's a new one to me.

Dr. Agarwal: Yeah. Most people haven't heard it.

Dr. Jones: Right. Very rare.

Dr. Agarwal: And it's not a breast cancer as we think of breast cancers. It is a lymphoma. It's typically found in the capsule, the scar tissue that surrounds a breast implant. But again, I want to emphasize that it's exceedingly rare.

Dr. Jones: If there's an increased risk, what kind of numbers are we talking about?

Dr. Agarwal: We're talking about really low risk. It appears that patients with breast implants have about a one in 3,800 to one in 30,000 risk of developing this type of lymphoma. To put that in a broader context, you can think that the average woman in the United States, one in eight women will develop breast cancer.

Dr. Jones: In their lifetime, yeah.

Dr. Agarwal: In their lifetime. So this is orders of magnitude lower than that risk.

Dr. Jones: So it's very small or . . . this is where I put it in the teensy when I . . . this is my teensy risk.

Dr. Agarwal: That's correct.

Dr. Jones: However, it's a scary thing because many women who are having implants are maybe not doing it for cosmetic purposes but for reconstructive purposes, and they already have cancer on their brain and their heart. What kinds of breast implants are the most likely?

Dr. Agarwal: So what we've seen, first of all, there have been about 400 to 500 cases of this ALCL reported to the FDA. And after looking back at those patients and the types of implant they've had, it appears that the highest association is with textured breast implants.

Dr. Jones: So tell me about that. I don't get textured. Is textured meaning its outside is kind of rough, or what do you mean by textured?

Dr. Agarwal: That's correct. So breast implants come in a variety of styles. The first you may know is saline-filled implants or silicone-filled implants. And then another characteristic can be whether they have a smooth outer surface or a textured outer surface.

We started using textured implants because there was a thought that maybe it decreased the amount of scar tissue that formed around the implant or what we call capsular contracture. Sometimes we use implants that are slightly shaped, and the texturing helps prevent the implant from turning. But the association with the ALCL is the highest with the ones that have a texture on the outer surface.

Dr. Jones: Well, that has some biological possibility. I mean, it could cause a different kind of reaction than a smooth, slippery one.

Dr. Agarwal: It could. It's possible that the texturing creates more inflammation or an area for bacteria to reside and cause an inflammatory response.

Dr. Jones: You mentioned that it's in the capsule or the area around the breast implant. How does this present? Because quite frankly, when we think about lymph cancer, I think about lymph nodes, I think about armpits, neck nodes. I wouldn't think of looking at the breast itself. So how might it present if I were an OB/GYN or a clinician? What am I looking at?

Dr. Agarwal: Right. So patients who've had breast implants can present to their physician, OB/GYN, general family physician, or their plastic surgeon with a variety of different complaints. The breast is swollen, it's become more painful, or they feel a mass. The most common presentation is fluid around the implant. And about 86 percent to 90 percent of patients who've had this ALCL presented with what we call an effusion or a seroma around the implant.

Dr. Jones: Was it years after their implant or . . . it must have been years because cancer doesn't happen in a day.

Dr. Agarwal: Right. So the average time to presentation of the 400 to 500 patients that have had this has been 8 to 10 years after the breast implant has gone in.

Dr. Jones: Right. So if it's 400 in the U.S., that means the vast majority of plastic surgeons, OB/GYNs, primary care docs, nurse practitioners have never seen this, have never heard of it. But if a patient comes with a new complaint some years after the breast implant should be pretty stable, they should know enough to say, "That's not normal."

Dr. Agarwal: That's correct. Again, to put it in a little bit of context, as you mentioned in your opening, there are about 300,000 to 500,000 breast implants that are placed annually in the United States. It's believed that worldwide there are about 35 million women who have textured implants, and it's believed worldwide about 1.5 million implants are placed annually.

So, again, small numbers, but any OB/GYN, family physician, plastic surgeon should be made aware of this, because as we're learning more about it and as we're observing our patients more closely after they've had implants placed, we're identifying more cases of this. And while the number is small, we don't know where it will end up at.

Dr. Jones: Right. Well, when we're talking about breast cancer, even a very rare one, people think about this being lethal. So, when this presents, is this usually a cancer that's spread already? Do most people die from this cancer? What happens when people find this cancer?

Dr. Agarwal: Most of the time with ALCL that's associated with breast implants, the cancer resides locally in the tissues around the implant. And for most of the cases, removal of the implant and removal of the capsule, the scar tissue around the implant can cure the patient of the lymphoma. In rare instances, the lymphoma can spread to the lymph nodes or elsewhere, but the most common presentation is a local one.

Dr. Jones: Well, that's actually great news for a rare cancer, for it to be actually mostly curable with the surgery, just remove the implant and capsule. To me, as a provider and as a woman, that's very reassuring to me.

Dr. Agarwal: Yes. Nobody wants to have an increased risk of anything if they're having a medical device placed. The good news is (a) it's very rare, and if caught within an early period of time, it can be cured by removing the implant and the capsule. If there's something good about it, I'd say.

Dr. Jones: That's right. I think that's good news about bad news.

Dr. Agarwal: Right. I will say that at the University of Utah and Huntsman Cancer Hospital, we have placed a moratorium on textured breast implants. We no longer place any textured implant until the medical community and the FDA learn more about this ALCL, and until we feel confident or have some better understanding of what the true association, if there's really a cause and effect association.

I think you want to ask all the right questions as a patient. What type of implant am I having placed? What are the risks of the surgery? What are the risks of the implant?

From the physician side, it's important to do a full physical exam when your patient comes in for their annual visit. That includes a full breast exam, particularly in patients who have had breast implants. If a patient notices anything suspicious or a change in the shape, size, or feel of their breast, they should bring it to the attention of their physician. And if an OB/GYN or a family practice doc has concerns, they should then have the plastic surgeon involved.

The FDA at this point recommends that either an ultrasound or an MRI can be done as a screening tool. Anyone who has symptoms should go directly to MRI. Anyone who has an implant placed, particularly a textured implant, should have a screening MRI after five or six years after the implant was placed.

Dr. Jones: Well, for many women who are making the choice about breast implants, only they will be able to balance the risks and benefits in their own bodies. But we try to give them the best information that we have and help support them with their decision. Thanks, Dr. Agarwal, and thanks for joining us on The Scope.

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Recently the Food and Drug Administration (FDA) has identified a possible association between textured breast implants and development of a rare form of cancer called anaplastic large cell lymphoma (ALCL).

The majority of the data suggests the cancer risk is associated with breast implants that have textured surfaces rather than those with smooth surfaces. The risk is low and thus far only a small percentage of patients with textured implants have been found to have ALC in the United States. Nevertheless, out of an abundance of caution the FDA has recalled a specific brand of textured implants.

The Division of Plastic Surgery at U of U Health has stopped using all brands of textured implants in light of the recent concern of developing ALCL. Please note that the recall of these implants does not mean that the implants need to be removed. If you have concerns or questions regarding the recall please refer to the FDA website or speak with your doctor.

For More Information About the FDA’s Ongoing Status on Breast Implants and ALCL

Dr. Jones: Disfigured, mutilated. These are words that are the way some women feel after mastectomy, the extensive surgery for breast cancer. What can we offer women who have had this surgery, to help them recover their self-image?

Dr. Jones: About a quarter of a million women will be diagnosed with invasive breast cancer in the US this year. Some will choose a smaller operation, a lumpectomy, but many will choose a larger surgery in their hope for a cure. And the percent of women choosing mastectomy is increasing. Although we're grateful for the treatments that can cure breast cancer, mastectomy can leave a woman and her body image profoundly changed. The Scope's Seven Domains of Women's Health team is in the office. I've Dr. Agarwal, a breast reconstructive surgeon at the Huntsman Cancer Institute, and we're going to talk about breast reconstructive surgery. So, Dr. Agarwal, tell us a little about your training. How is it different from a breast cancer surgeon, the person who did the mastectomy?

Dr. Agarwal: Well, I'm a plastic and reconstructive surgeon so my role is to try and rebuild. After a patient undergoes a mastectomy by the breast cancer surgeon, I work with the patient to try and then rebuild the breast. And this can be really any part of the body. As a reconstructive surgeon, our goal is to try and restore form and function for a patient.

Dr. Jones: Can you do the reconstruction at the time of the mastectomy, or are there advantages of doing it immediately versus delayed?

Dr. Agarwal: You can do the reconstruction at the time. We often, in fact, start the reconstructive process on the same time, in the same operative setting as the mastectomy surgery. Sometimes, it's a staged operation in which the first stage is started at the time of mastectomy and then the subsequent stages occur in the future. And sometimes, you can complete the entire reconstruction all in one setting.

There are advantages and disadvantages to doing it all at once. Some patients like the idea of just having one operation or, at least, having one operation where the majority of the surgery is done. Some patients like waking up from the operating room with the start of a creation of a breast, rather than waking up with a flat chest. The downsides are it does add surgery time and does add recovery time to the operation, but, in general, we're starting to see an increase in the number of patients that are having reconstruction that is initiated at the time of mastectomy.

Dr. Jones: Right. So women actually use to think of reconstruction as something that came to them six months or a year later when they felt like they were cured of their cancer and they were really ready to go on with the next step of their life. But now I think women are expecting to walk out knowing that they're going to feel a little bit more like themselves.

Dr. Agarwal: I think that's true. I think, in the past, reconstructive surgery was often considered something that was not part of the cancer care process of a patient. And today, reconstructive surgery and the role of a reconstructive surgeon are really integral into the entire comprehensive care of a cancer patient.

Dr. Jones: Right. So what's changed with our new tissues, new materials?

Dr. Agarwal: The types of surgeries we do and the technologies that we have have improved. We don't quite have the 3D printing of a breast down yet, although we may get there in the near future. But the quality, the implants, the implant material, and the ability to use tissues from different parts of the body has really improved dramatically over the past 15 years.

Dr. Jones: So we're using some of the woman's own tissues for some of the breast, and some implants, or combinations?

Dr. Agarwal: Both scenarios. So patients can have implants only, their tissue only, or a combination of implant and their own tissue. And that sort of depends on their body, their choices, and what may be the best option. And that often requires a discussion with their surgeon.

Dr. Jones: Well, honestly, Dr. Agarwal, as a woman, my personal fear about mastectomy, with or without reconstructive surgery, would be that I would be asymmetrical, that I'd have one normal breast and one plastic breast, and I just wouldn't be balanced. And I feel that breast had betrayed me already, and I wouldn't want to have breast cancer in the other breast. So I might ask you as if I were your patient to just do them both, so make them, when we're done, they can both look the same and be the same. Are you getting more requests? Does this sound crazy?

Dr. Agarwal: This isn't crazy. In fact, we're getting an increasing number of requests for bilateral mastectomy and reconstructions. And it's a very personal choice, it's not a choice that every woman makes, and it's not an easy choice. I think there are a lot of factors that go into it. Fear is, by far, the biggest factor. Patients exactly like you said, patients are worried that they might develop cancer in their other breast, or they're always going to be nervous and can't sleep at night and so they want to be free of that fear. And that's a real consideration when we consider doing a bilateral mastectomy.

I will say, though, just like any surgery, you have to be prepared that the more surgery you do, the more recovery, the more potential for a problem. So think carefully, talk to your surgeon, talk to your family before you make these decisions.

Dr. Jones: Fears of cancer and fears of disfigurement may lead women to avoid mammograms or seeking medical help if a lump is noticed. There are many more options for women as they face the challenges of breast cancer, and challenging, and living after a breast cancer treatment. Dr. Agarwal, thanks for helping us and think about our options, and thank you for joining us on The Scope.

updated: June 17, 2021
originally published: October 22, 2015

Dr. Jones: When women have had breast cancer surgery, the major surgery such as a mastectomy, they are often looking forward to living their lives and getting their body back. What are the new steps and what are the things that we have here at the Huntsman that will really help them make this difficult decision? How do we make the decision, and who is the team involved?

We are in the office of Dr. Agarwal here at the Huntsman Hospital with a beautiful view out the back door of people living their lives. I want to talk about how women who have had mastectomies make the decision to live their lives going forward as they make the transition from a cancer victim to a cancer survivor. We're talking about breast reconstruction here with Dr. Agarwal, plastic surgeon and reconstructive surgeon here at the Huntsman Hospital.

Let's talk a little bit about women who request the bilateral mastectomy. Of course, there are women with BRCA mutations, mutations that increase their risk of cancer. They don't have cancer yet, but both of their breasts are going to be involved so that's pretty easy to understand. How about if a woman has breast cancer on one side and wants the other one done? Does insurance pay for that?

Dr. Agarwal: Not always. We're seeing an increased demand, if you will, in patients who want to have the contralateral breast removed. A lot of times, this is driven by fear of developing cancer in the other breast. Oftentimes, it's driven by the desire to have symmetry and it's not a guarantee that your insurance will pay for this. More and more, we're seeing that insurance wants to really focus on the breast that has cancer and may not always pay for removal and reconstruction of the other breast.

But any time a patient has these concerns or desires to have both breasts removed, it requires a good discussion with their doctors, their oncologists, their surgeons because while things like symmetry may be improved in some cases, there are also potential consequences to having your other breast removed. You lose sensation of an otherwise normal and healthy breast. Just like with any other surgeries, there is the risk of potential complications by adding more surgery time or more operations.

Dr. Jones: And if women are young enough that they might want to consider having children if they get past their diagnosis and are cured, then they couldn't breastfeed if they have bilateral reconstruction and that has to be discussed. There is so much on the Internet about the pros and cons, but are there other women that someone can talk to? Do you have support groups of women who have made decisions and how they worked through their decisions? How do women go about finding out more information?

Dr. Agarwal: There are definitely support groups here at the Huntsman Cancer Hospital. There are teams of patients who have offered their services to other patients because they've gone through this process in the past and they give the whole picture, the good and the bad of going through this process. Throughout the Salt Lake community, there are organizations that provide a lot of information to patients, including Susan Komen's Foundation. So there are definitely support groups. I think that it is a very personal decision in the end and I think that a frank conversation with your medical team and your family is important when finally making these types of decisions.

Dr. Jones: Let's talk briefly about nipple reconstruction. I've heard that you have an amazing tattoo artist here at the Huntsman who might be able to even tattoo a nipple or are you using other tissues for nipple reconstruction?

Dr. Agarwal: First of all, we do have a great tattoo artist here at the University of Utah and Huntsman Cancer Hospital, but there are different ways of reconstructing a nipple. We can actually use some of a patient's own tissue to create the nipple itself and then tattoo the areola around it. And another option is to purely use tattooing. Some of the tattoo artists can create 3D tattoos of a nipple, which looks amazing. They look like real nipples that have projection even though they're flat on the surface of the skin.

Dr. Jones: That must be very gratifying to have the ability to give a woman that gift, not only as a reconstructive surgeon to give the gift of having symmetry and a self-image that will carry her forward as she works through her recovery but even having the ancillary staff that can help her through that like the tattoos and the counselors and therapists and all of the people, a whole team that can take care of people.

Dr. Agarwal: It's absolutely gratifying to see a patient go through this process and come out feeling whole again and feeling like they can get past or move beyond their initial diagnosis of cancer, and that's really the goal is to help them move forward in life.

updated: June 8, 2021
originally published: October 22, 2015

Scot: Did you realize that leeches are still used in modern medicine? Well, they're about to be out of the job. That's coming up next on The Scope.

Announcer: Examining the latest research and telling you about the latest breakthroughs. The Science and Research show is on The Scope.

Scot: Dr. Agarwal, it really surprised me, first of all, to find out that leeches are still used in modern medicine. Really?

Dr. Agarwal: Yeah, it's true and it actually surprises a lot of patients too, but there are situations where we need leeches and they're currently used and available in the United States.

Scot: What types of conditions would you need a leech for? What's a patient do when you bring in some leeches?

Dr. Agarwal: In order for tissue to live it has to have arterial blood flow in, and invenous blood drain the old blood out. If there's a pooling of blood or the venous system is not functioning properly the tissue can't get new, fresh oxygen or nutrients and it has a harder time healing and surviving. So leeches come into play when this pooling occurs. What we do is we attach a leech onto that piece of tissue that's struggling, and the leech will then suck out the pooled venous blood. This allows for new oxygenated blood to enter the area, and the process goes on until the tissue has had enough of a chance to heal on its own.

Scot: So they're about to be out of the job. There's a brand new mechanical, a robotic leech. Explain how one makes one of those.

Dr. Agarwal: I took the idea to a group of students in mechanical engineering and we sat together and I explained to them what leeches are, what they're used for, and we discussed ideas of how to make a better device and replace existing leeches. The students then got together with myself and Dr. Bruce Gale who is a Professor in Mechanical Engineering, and brainstormed ways to develop a mechanical device that could do the functions of an actual leech. What they've come up with is an exciting new piece of technology that really can mimic the properties of an actual leech. It has the ability to suck out the pooled blood, and it can also deposit a little bit of anti-coagulant in the tissue to keep the blood flowing, which is what we want.

Scot: So, if it ain't broke don't fix it. Why did you decide there was a need for a robotic leech, or a mechanical leech?

Dr. Agarwal: Traditional leeches are a little cumbersome to deal with. Number one is they have to be cultivated and maintained. They often are not something that patients like to have on their skin, and they can transmit diseases. They harbor bacteria which can then get transmitted to the tissue or to the patient and cause problems.

Scot: Are their any downsides or things you're trying to work out with the mechanical leech?

Dr Agarwal: The next step is to do some clinical studies to show that it really can function effectively, and even better than a traditional leech.

Scot: Do you expect little picket lines of leeches outside your office anytime soon?

Dr. Agarwal: You know what, that's fine with me. I think putting leeches out of business is not a bad thing. They can live in the swamp where they belong.

Announcer: Interesting. Informative. And all in the name of better health. This is The Scope Health Sciences Radio.