A triplet of features on breast cancer

A few interesting things on breast cancer caught my eye the last week or so.

For starters, the Tuesday (Dec 26) New York Times had an outstanding interview with Dr. V. Craig Jordan, one of the directors at the Fox Chase Cancer Center in Philadelphia. The topic of discussion was how to make sense of the recent story on the dramatic decrease in breast cancer rates we've observe since hormone replacement therapy (HRT) after menopause became less common.

Adjacent to that was a story revisiting the effectiveness of women performing self breast exams. Promoting self-exams to detect breast cancer has been dogma for years, but does it work? The research seems to indicate that it is not very effective and leads to a significant number of unnecessary procedures. A number of epidemiologists have advocated dropping self-exams as a recommendation, but have run into a buzz-saw of controversy from breast cancer activists and some physicians.

I personally think there is little utility (at least on a systems-wide analysis), especially when women have fibrous breast tissue. It is impossible for me in fibrous breasts to sort out anything. I've been very impressed with the ability of ultrasound to quickly characterize masses accurately and proceed to needle biopsies as needed. On the other hand I have had patients find lumps themselves that do in fact turn out to be cancer. For most women, annual mammograms and a physician breast exam are going to be effective.

There is a classic TV ad about self-exams from the Canadian Breast Cancer Society from a few years ago that still cracks me up where a geeky teen offers up his services for breast exams to the smooth sounds of Barry White. America is too uptight to ever use humor this effectively.

Thru the magic of Youtube.com you can click on the screen below to see it:


The most odd-ball feature is this one from the BBC titles "Housework cuts breast cancer risk.".

The research on more than 200,000 women from nine European countries found doing household chores was far more cancer protective than playing sport.... Housework cut breast cancer risk by 30% among the pre-menopausal women and 20% among the post-menopausal women

I'll be sure to get a reprint of this for my wife :)

Phony plastic surgeon is ordered to pay $5 million

Another tragic example in the Latino community of a poseur performing cosmetic surgery came to it's conclusion recently. If you remember last summer, this well-documented episode near Boston where someone died after complications from liposuction performed in the basement of an apartment complex.

Cuban national, Reinaldo Silvestre, operated in an unliscened medical clinic in the late 1990s in Miami Beach. He offered very low rates and dealt primarily with immigrants who wanted plastic surgery. Silvestre, "the Butcher of South Beach", abruptly abandoned the United States in Miami Beach in 1999 when investigations into his practices began after a number of complaints. He was collared five years later in Belize, where he was performing surgeries and aparently a faculty member at a local medical school. One of his students saw an America's Most Wanted episode profiling him and alerted authorities.

A victim of a botched breast surgery necessitating nearly $100,000 USD in reconstructive surgery was awarded nearly $5 million USD for pain and suffering. As a foreign national with no assests here, it would seem likely that little if any of this award will be realized (and remember 30-50% of the award often goes to the attorney).

Apparently Silvestre also had occasion to videotape surgery (a screen capture pic is shown below) on a male patient, former Mexican national champion bodybuilder, Alex Baez. Baez had gone in seeking pectoral implants, but awoke to find he had been given female breast implants. Baez's attorney says his client was anesthetized with horse tranquilizers, and actually woke up several times during the surgeries. El doctor Silvestre was also demonstrated using kitchen utensils for parts of the surgery.

Spencer Aronfeld, a lawyer for several alleged victims of Silvestre, said Mr. Baez wanted pumped-up pectorals but came out of surgery performed by Silvestre with what looked like women's breasts

"So this big bodybuilder from Mexico wakes up from this surgery expecting to look like Tarzan and instead he looks like Pamela (Anderson Lee), Dolly Parton,"

A detailed narrative from Maxim magazine about this can be read here.



That is not what male pectoral implants should look like (if you couldn't figure that out already)! They tend to be low-profile flat devices traditionally molded from semi-solid silicone rubber rather then silicone rubber shells filled with gel as implants for breast augmentation or reconstruction are.

What to make of suicide rates and breast augmentation patients?

A trend has been identified in several studies of patients with implants which briefly merited some attention last summer, namely that increased suicide rates has been observed among implant patients in some of the large European databases.




Does this suggest that implants actually cause suicide? Absolutely not.

Rather, it likely reflects selection bias (a phenomena where accurate conclusions from statistical analysis is undermined) in the studied patient groups.

What's that in this instance?
An increased incidence of mental illness and depression among prospective patients.

One of the Danish studies reported that the women with breast implants had almost double the rate of psychiatric morbidity as those in the control groups. This data is easier studied in countries with centralized health care as exists in Canada & Western Europe, and is where most of this information comes from.

It has been suggested that a psychiatric condition, body dysmorphic disorder may explain the elevated suicide risk among breast implant recipients. Earlier research from the University of Pennsylvania Center for Human Appearances (Yes, there actually is such a thing!)suggested that as many as 15% of cosmetic surgery patients have the condition, characterized by preoccupation with small or imagined defects in appearance.

About 80 percent of breast implants in the United States are for cosmetic reasons and 20 percent for breast reconstruction after breast cancer surgery. Dr. Leroy Young, a Plastic Surgeon from St. Louis,one of the world's experts on silicone implants and a respected basic scientist speculated a few years ago that the data trickling in may in fact no longer be applicable to today's breast augmentation patient

“In the 1960s and '70s, women in the U.S. who had breast augmentation tended to smoke, drink alcohol, and report other risk-taking behaviors more often than the general population, but our findings suggest that this is no longer the case,”.

A recent survey of 5,000 women in the U.S. who had either received breast implants or were considering them found that the women were less likely to drink alcohol and smoke than the general population. Young says these women had a lower frequency of signs of depression than did the earlier generation of American implant recipients and the women in the European studies.

Is there a plausible explanation for breast implants causing suicide?
Not really. Some anti-implant activists are suggesting something along the lines that implants cause so much psychic or physical pain that it must be driving these women to killing themselves.

Jacques Brisson, M.D., D.Sc., of Laval University in Quebec City and lead author of the largest study which has noted this phenomena had this to say:

"Recently, it was suggested that complications experienced by women who received breast implants could contribute to increased despair, which may increase the chance of suicide," the authors said.

However, our findings to not support this hypothesis because we found no increase in the standardized mortality ratio for suicide with increasing length of follow-up," they said. "Additionally, there were no differences in suicide rates between implant patients and other plastic surgery patients."

The most recent such study, presented by Dr. Brisson, was performed in a population much larger then the others in a group of Canadian women. (see here for a blog entry I did on this last summer) Like the other work, there was an elevated suicide rate. However, the suicide rate was similar to that of women who had other cosmetic plastic surgery procedures which further strengthens the belief that breast augmentation (and indeed all cosmetic surgery) has a correlative relationship to depression/mental illness rather then a causative one to suicide.

Will today's patients have similar such rates or will observations like Dr. Young's ultimately prove correct. Check back in 10-15 years.

Plastic Surgery Stocks

I saw a really interesting analysis of the stock prospects of several of the major cosmetic medicine & Plastic Surgery industry companies on The Street.com, specifically the heavy hitters Allergan-Inamed, Mentor, & Medicis are all spotlighted, each incidentally is up ~10% for this year.

There are a lot of competing products hitting the market as Allergan's new injectable filler, Juvederm tries to unseat the popular Restalyne (from Medicis). Likewise, Medacis' Reloxin (a drug similar to Botox) should hit the market in the US next year. Hopefully that will lower the price of some of these injectables.

Things are set to heat up in the US implant market with the recent silicone implant reintroduction. The article writes,

"Allergan and Mentor are the dominant players in this $500 million to $600 million global market segment. Most analysts expect 30% to 40% first-year conversion rates of the saline-implant market, but early gains may be greater, as a result of pent-up market demand. The anticipated switch to more profitable implants supports a strong revenue outlook and further margin upside for these two players in '07."

I personally think an estimate of 30-40% market share for silicone is on the low end talking to other surgeons. Meanwhile, my savvy Plastic Surgery stock-pick of Ivivi is now sitting a full 10% below it's IPO price. I guess my kids will be going to state instead of Princeton :)

Breast reconstruction using own twin

In this weeks' PEOPLE magazine, there's a feature on twin sisters from Pennsylvania who underwent an unusual type of organ transplantation. After radiation treatments and a failed implant-based breast reconstruction, Naomi DeSalvo Whinnie turned to micro-surgeon extraordinaire Dr. Bob Allen in Charleston, SC for help.

Dr. Allen is the father of the "DIEP" flap for breast reconstruction, an operation that uses microsurgical techniques to transfer tissue from the abdomen to the chest and performs more then 100 hundred such reconstructions annually. The catch here is that the tissue in this case was provided from the abdomen of Mrs. Whinnie's identical twin sister, Nina DeSalvo Hildebrand. This operation can be performed on twins without intense immunosuppression because their immune systems do not recognize the tissue as foreign and reject it. This is the third such twin-twin DIEP flap Dr. Allen has performed in what is likely the largest personal experience in the world.

Seen below are the sisters shown recovering in a shared hospital room.

The trial bar searching for new targets.

Two articles in today's Wall Street Journal provide an interesting lesson in the way the trial lawyers treat medical device issues.

The first article,"Panel Supports Drug-Coated Stents " describing the conclusions of an FDA advisory panel on drug-eluding stents (small metal tubes which prop open clogged arteries) which have the potential for keeping arteries open longer then the traditional bare metal stents. An issue at those hearings is whether the drug-coated stents are tied to a small but significant danger of potentially deadly blood clots. This is still being sorted out, but most feel these types of stents have saved a significant number of lives and it is likely there will be more refined indications on who benefits more or less from using these.

Adjacent to this is an article titled "Stents are Galvanizing the Plaintiff's' Bar"

Some patients and lawyers aren't waiting (for studies)to file lawsuits, claiming manufacturers of the devices failed to warn them of the possible clotting risks, and of a severe itching problem caused by a hypersensitive reaction they allege can develop after stent implantation

The case comes amid a surge of lawsuits against pharmaceutical and medical device companies. The shift has taken place as massive lawsuits against tobacco and asbestos companies have dried up....

So as the perpetual feeding trough of the asbestos issue is disappearing, you can see each & every drug and device being eyed as the next cash cow for extorting settlements from industry. If the silicone breast implant debacle of the early 1990's taught us nothing, it's that science should not be established by lawyers in a court but by researchers in clinical trials. Does the plaintiff bar actually care about the truth in these cases as they're furious registering sites like www.harmedbycoatedstent.com to recruit clients?

Safer surfing on the cheap

As an aside from Plastic Surgery I'd like to highlight a few FREE resources that will make your Internet experience safer. As computer viruses, mal-ware (programs that cause problems with your computer), email SPAM, tracking "cookies" (bits of code that can trace your activity), key-stroke logging (programs that record all keyboard activity), and Phishing (obtaining secure information using false pretenses) are increasingly common, you should not be using the Internet "naked".

There are many excellent commercial software programs (ie. Norton's, McAfee, etc..) and built-in Windows features which help with this, but you can get many of these types of programs for free which are superior to the included Windows programs. (follow the highlighted text for direct links)



AVG Anti-virus has an outstanding free anti-virus with updates for non-commercial users


Spybot S&D is the atomic bomb for destroying malicious software, tracking cookies, & key-stroke logging programs



Zone Alarm is an award-wining firewall which has a great bare-bones free version

Two new breast cancer devlopments worth watching

A few intersting things in the press about breast cancer.

First, a new technique of ultrasound imaging of breast masses called "Elasticity Imaging" is being described. It attempts to characterize mass as benign or malignant based on the degree to which it can be manually compressed and the speed with which it resumes it's original shape. The potential benefit of this is that it avoids requiring obtaining a tissue biopsy (by a surgeon or radiologist)and evaluation by a pathologist. The risk is that ultrasound is very dependent upon the skill and subjective judgement of the user. The accuracy of this is still being evaluated in larger clinical trials which will compare the ultrasound interpretation to the actual biopsy reports.

Second, RU-486 ("the abortion pill") has shown the potential to signifigantly reduce the development of breast cancers in mice who are bred with the BRCA-1 gene, which is one that causes breast cancer in women by causing the hormone progesterone to more actively stimulate breast tissue proliferation. More than half of women with this gene will develop breast or ovarian cancer by age 70.