Fw: The Breast Cancer Information Gap by Dr. Zuckerman

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From: " ilena rose " <ilena@...>

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Sent: Wednesday, February 27, 2002 9:52 AM

Subject: The Breast Cancer Information Gap by Dr. Zuckerman

Bravo Dr. Zuckerman!

(posted on alt.support.breast-implant/sci.med.nursing)

Dear Friends,

Here is a copy of an article we just had published in RN Magazine,

entitled " The Breast Cancer Information Gap. " The purpose is to provide

nurses with information about using implants for reconstruction after

breast cancer, in hopes that they will provide more accurate information

to their patients.Ý We offered to write this article after RN magazine

published an article and test for CME (Continuing Medical Education)

credit which had incorrect information about implants (for example,

saying they were approved by the FDA when they were not at the time).Ý It

took a while to get it published, and they made a few errors and

additions that we didn't especially want, but we think it will provide

useful information that will help a lot of patients, and the nurses who

care for them.

I have cut and pasted the article, and also attached the version with

footnotes.Ý It will be on our websites, with photos, within a few days. Ý

Best wishes,

Zuckerman, Ph.D.

National Center for Policy Research (CPR) for Women & Families

1901 Pennsylvania Avenue, NW

Suite 901Washington, DC 20006202 223-4000

www.center4policy.org

www.breastimplantinfo.org Ý

This article was published in RN Magazine, February 2002

The Breast Cancer Information Gap

DIANA ZUCKERMAN, PhD

Breast cancer patients who are considering reconstructive surgery

following a mastectomy many not always receive the safety and

quality-of-life information they need to make a truly informed decision

about breast implants, this former Congressional investigator provides

the data you need to help fill that information gap.

Thanks to early detection, three out of four American women who are newly

diagnosed with breast cancer can safely choose breast-conserving surgery

rather than mastectomy.1 For those who choose a partial or complete

removal of a breast, many patients consider whether or not to undergo

breast reconstruction with implants.

In 1999, the most recent year for which statistics are available, nearly

83,000 women underwent breast reconstruction.2 Although breast implants

often have the desirable effect of helping to improve a woman s

self-image and body symmetry, their safety remains controversial. The

potential complications include pain, breakage, and a possible link to

fibromyalgia and other diseases.

As a former Congressional investigator reviewing studies submitted by

implant manufacturers to the Food and Drug Administration (FDA), and in

my current work on health policy issues, I have studied firsthand the

research on the safety of breast implants and quality-of-life issues

surrounding them. Here I ll share with you a number of things I ve

learned that you and your patients may not be aware of.

Safety issues patients may not fully grasp

There are two types of breast implants and they both have an outer

silicone shell; one type is filled with saline and the other with

silicone gel. Both were on the market for many years before the FDA

started regulating medical devices in 1976. When the agency began

reviewing safety data on medical devices, it gave priority to lifesaving

ones. As a result, the safety of breast implants wasn t reviewed until

1991.

The FDA started with silicone-gel implants because of concerns that

silicone leakage could be harmful. In 1992, dissatisfied with the safety

data from the manufacturers of these products, the FDA restricted the use

of silicone implants to patients undergoing reconstruction after

mastectomy, women with breast deformities, and those who had silicone

implants that ruptured and wanted them replaced.3 The FDA further

stipulated that these implants had to be used in ongoing clinical trials,

which would enable the agency to track patient data and evaluate implant

safety over time.

In 1999, the FDA reviewed safety data from manufacturers of saline

implants, and, in 2000, approved several styles made by McGhan Medical

Corporation and Mentor Corporation (both in Santa Barbara, Calif.) for

breast reconstruction in women of all ages and breast augmentation in

women 18 years or older.

Although silicone gel implants feel more natural, saline implants are

generally considered safer in the event of rupture. Yet, patients need to

understand that saline implants also have risks.

According to studies the FDA received from manufacturers of saline breast

implants, seven out of ten patients will experience at least one serious

complication within the first three years of receiving an implant, such

as pain, hardness, infection, or rupture of the implant.4 The most common

complication experienced by almost one-third of the women -- is a

condition called capsular contracture, in which scar tissue tightens

around the implant, causing the breast to become hard, misshapen, and

painful.5 Patients who have breastfed compare the sensation to being

unable to nurse their baby for many hours.

Not guaranteed to last a lifetime

Patients may also not be aware that a breast implants will break

eventually. A new FDA study shows that most implants break within 10-15

years, although some break within just a few months.6 One in four

patients have an implant removed within three years because of this

complication and others.

When the shell of a saline implant breaks, saline leaks out quickly, or

over several days. As a result, the implant gets smaller and may lose its

shape. Although the saline is absorbed by the body, the deflated implant

will need to be surgically removed.

Removing a ruptured silicone implant isn t so simple. Because silicone

gel is " sticky, " it can be difficult, if not impossible, to completely

remove from surrounding tissue. When a silicone implant ruptures, a woman

may feel the reduction in size of her breast, bumps, pain, tenderness,

tingling, or numbness. Some women, however, experience no symptoms at

all. In these so-called " silent ruptures, " gel may slowly migrate to

other parts of the body.

According to a recent FDA study of 344 women, 79% of the women who had

silicone implants for 11-15 years had at least one ruptured implant but

weren t aware of it.7 Their diagnosis was made by means of magnetic

resonance imaging (MRI), which also showed that silicone migrated away

>from the broken implant in one in five women.

There is only one study of the health of ruptured silicone implants, and

the results, though not conclusive, are disturbing. Those women were more

likely to be diagnosed with fibromyalgia or several other painful and

debilitating autoimmune diseases, compared to the other women with

implants. In addition, some women have developed symptoms of lupus,

rheumatoid arthritis, scleroderma, or other connective tissue diseases

that they attribute to their implants. Although most of these concerns

center around silicone implants, similar symptoms have been reported

anecdotally among women with saline implants, which have a silicone shell

that may " leak " small amounts of silicone.7

Even more disturbing, two recent studies by the National Cancer Institute

found that women with silicone or saline breast implants were more likely

to develop cancer than other women their age, and more likely to die from

brain cancer, lung cancer or other lung disease, or suicide, compared with

other plastic surgery patients.9,10 These studies, however, didn t

include reconstruction patients, and more research is needed before

conclusions can be drawn. Meanwhile, a connection between breast implants

and serious diseases can t be ruled out.8

Women who have a saline or silicone implant removed but not replaced may

describe the experience as " losing their breast twice, " but this decision

is appropriate for women who want to avoid future complications.

Talking with patients about their options

An important part of counseling patients is listening without making

assumptions about what patients need or want. Many of us might assume,

for example, that breast reconstruction improves the quality of women s

lives. Yet the most recent research by the National Cancer Institute

concludes that women who undergo mastectomies report the same levels of

satisfaction with their lives whether they undergo reconstruction (with

implants or autologous tissue transfers such as TRAM--transverse rectus

abdominus myocutaneous flaps).11 In fact, mastectomy patients who

underwent reconstruction were more likely to report that breast cancer

had a negative impact on their sex lives than women who didn t have

reconstruction.

Such findings remind us that we can t predict what is best for patients.

What we should do is provide them with options and support their choices.

Patients who decide to undergo breast reconstruction with implants may

ask your advice about the timing of the surgery. It can take place at the

time of tumor removal or months or years afterwards. Immediate

reconstruction may reduce costs by combining mastectomy and implantation,

although patients may face a longer operation and recuperation. Other

patients may prefer to delay reconstruction so that they have more time

to consider their options or to complete chemo- or radiation therapy.

(For details on nursing care for breast reconstruction patients, see

" Oncology Today: Breast reconstruction, " RN, April 2000.)

Regardless of the timing of surgery, additional procedures are often

needed to complete the reconstruction. Breast reconstruction with

silicone gel is a one-stage procedure. With a saline implant, the surgeon

must first insert a tissue expander, and, over several weeks, inject more

saline into the expander so that it gradually stretches the muscle and

skin. Eventually, the expander is surgically replaced with a saline

implant.

With either type of implant, at a later point, the patient may want a

skin graft to creat a new nipple or may undergo surgery on her other

breast to make the two breasts look more similar in shape and size. So

even if there are no complications, many women undergo several surgeries.

Breast implant patients should be encouraged to report any pain, bumps,

loss of size or shape, and other symptoms of a problem. Because the

implant can interfere with the detection of a tumor during mammography,

the patient should insist on having a specially trained technician

conducting that test. The technician needs to take precautions to avoid

rupturing the implant during compression and take special views of the

breast to detect tumors that might be obscured by the implant.

Patients deserve to be given information about what is known and not

known about the safety of breast implants. When they know the risks and

benefits, they will be more satisfied with the decisions they make. For

more information on the safety of breast implants, visit the FDA website

(www.fda.gov) and key in " breast implants " in the search box. The Web site

of the National Center for Policy Research for Women & Families

(www.center4policy.org) provides additional links to women s health

research. With your help, patients can make the decision that s best for

them.