Mammograms in those with breast cancer predisposition

Lots of new interesting things continue to come out in my areas on interest.

Today, in Britain's Journal of Clinical Oncology, specialists said women genetically predisposed to developing breast cancer should consider asking for MRI scans, which do not use radiation, instead of mammograms. A news summary of it can be found here

This study retospectively questioned about 1,600 patients identified as high risk for breast cancer. These women, who possessed one or both of the well-known BRCA-1 & BRCA-2 genes that predispose them to breast cancer, may in fact be at significant risk for developing cancer from an imaging procedure which has been considered to poses little risk to women. These patients demonstrated an increased risk by as much as 2.5x by age 40, which is a staggering figure in risk analysis.

The researchers propose that radiation may be very risky for BRCA mutation carriers as those genes are believed responsible for repairing DNA damage, such as that from the ionizing radiation of x-rays. Defective genes would thus be less able to repair radiation damage, and result in more malignant cells developing.

The study "is not enough to mandate changes in clinical practice," said Dr. Kathy Albain, director of the breast research program at Loyola University Medical Center in Maywood,IL. "But I think it's enough to modulate our recommendations for certain patients.


A few things to keep in mind on this:
1. The study wasn't prospective
2. Most breast cancer cases (>90%) do not involve BRCA 1 & 2 genes
3. This finding has not been observed (yet) by other researchers
4. More prophylactic mastectomies are likely to be recommended in these patients

This is potentially big news thought for what may be a hastening of the eventual change to MRI mammograms being used more widespread which will be a good thing.


Rob Oliver

The hits keep coming....

This is becoming redundant I know, but there continues to be a flurry of new literature and announcements re. breast implants and their safety.

Following in the heels of April's report on the lack of cancer risk found in Danish implant patients in the Journal of the National Cancer Institute (see recent blog entry below), a publication about to be released in the American Journal of Epidemiology reports that a cohort of nearly 25,000 patients in Canada were observed to have a whopping 43% lower incidence of breast cancer and across the board lower mortality rate for all cancers.

A summary by CNN online can be read here

These two reports do not give evidence to suggest a protective effect of implants, but probably reflect a selection bias of patients choosing breast surgery. Presumably these patients are younger, healthier, and with less breast tissue then society at large. There have been some left-field theories on how the presence of implants could be tumor-supressive by lowering the temperature of the adjacent tissue or that there could be an immuno-stimulatory effect of a foreighn body. Neither of these ideas has been examined in a meaningful way.

The take home message: There appears (at this time) to be no evidence in multiple, well-done studies of a causitive relationship between breast implants and cancer.

Reading the tea leaves with the FDA on breast implants & platinum toxicity

In April, the Washington Post featured a story on a report that new, highly reactive species of Platinum free radicals were found in patients with silicone implants. This story was immeadiately seized upon by groups who have been fighting against liberalized reintroduction of silicone breast implants in the United States. In fact, the study referred to, was in part funded by one of these groups.

The Washington Post feature was not particularly partisan, but it did seem to highlight a single study out of context to the body of literture on platinum chemistry, which to that point was pretty dismissive of associations to toxicity. The article did however, get picked up in some scattered newspapers.

Just this past week the FDA updated their information page on breast implants and platinum and they made some interesting statements. Of the study referred to in the Post, they characterized it as have so many flaws as making it of "limited value". Irregular tests performed in the study and control groups makes interpretation difficult, and they point out that several members of the control group had higher levels of platinum then those with the implants.

They conclude that in vivo properties of platinum "do not represent a significant risk to women with silicone breast implants" which is consistant with their previous position, the 1999 Institute of Medicine report, the United Kingdom medical device committee, and a number of other reviews.

The publication of such a strongly worded position on the FDA site makes it seem likely to me that concern over platinum is unlikely to figure much in the timetable for the reintroduction of silicone implants.

more MRSA news - now in tattoo equipment

Echoing the the theme I mentioned previously, multidrug resistant Staph. infections (MRSA) are popping up more and more. The newswire today features a story infections in several states from improperly cleaned tattoo instruments.

boob-u-mentary

I found a great blog called Boobumentary following a patients recovery from recent breast augmentation. This is very illustrative of the early recovery and common experiences after many women's surgery.

Silicone breast implants & lack of cancer connections

This report in the April 19 Journal of the National Cancer Institute is fairly recent and something I meant to get around to highlighting.

An April 2006 report from the National Cancer Institute updated the world's most comprehensive long-term study of women with silicone implants and their risks of various cancers. Cancer-producing potential was one of the various claims made during the silicone histeria of the early 1990's.

In the report nearly 3500 women, who've been followed for an average of 18 years. Only 53 of the women developed breast cancer, compared to 71.9 cases that would have been expected in the general population. There were 180 total cancers in women with the breast implants, slightly fewer than the 193.1 that would have been expected. The women who received breast implants were more likely to develop lung cancer than other women: 20 developed it, compared to the 9.1 that would have been expected to have it. The researchers think this is because the Swedish women with implants were more likely to smoke.

This study is more reassuring information that continues to come in on the long-term safety of silicone implants.

To "T" or not to "T", that is the question...

One of the trends in breast reduction surgery is the trend towards "short-scar" procedures which minimize or eliminate the traditional horizontal part of the incision.

Seen below is a figure of the traditional "Wise Pattern" reduction using tissue from the lower part of the breast (an 'inferior pedicle technique') to keep the nipple & areola alive. It produces a scar that looks like an upside-down anchor and has been the standard procedure used in breast reduction for decades.



Work from surgeons in Europe & South America has trickled down to the United States using both shorter vertical scars with pedicles often oriented superiorly or medially. Below is a figure of a superior-medial pedicle which has been popularized by Canadian Plastic Surgeon, Dr. Elizabeth Hall-Findlay.


The advantages purported by this rethinking of the classic Wise-pattern/inferior pedicle surgery include using breast tissue (as opposed to skin) to maintain shape. Whether this holds up over time, we'll have to see. I've done a number of these & had some unpredictable results. They either are fantastic or just so-so. Unlike the traditional operation you rely on post-op settling of the breast to get the finished result which leads to some funky-shaped breasts leaving the table.

The most common problems I see are too high a nipple position & a persistant "pucker" at the bottom of the incision. Some puckers resolve, but a number require minor revisions in the office. It's always tempting to compromise the technique and use short-T's or j-shaped cut-outs of the pucker during the initial surgery.