Lack of appropriate imaging before breast augmentation can have serious patient consequences

Breast augmentation has become increasingly popular in recent years, with 316 848 procedures reported in the United States in 2011.1 While there is a lack of accessible data about breast augmentation procedures in Australia, the breast surgical oncology community has ongoing concerns about the potential for breast implants to deter women from participating in appropriate symptom assessment or routine screening and to impair early detection of breast cancer.2

The situation is complicated by a lack of high-level evidence about health outcomes for women with implants who subsequently develop breast cancer. In an observational study of 129 women who had undergone breast augmentation and 3953 women who had not, those who had undergone augmentation presented more frequently with palpable lesions, invasive tumours and axillary nodal metastases, and were more likely to have a false-negative mammogram result. However, overall there was no significant difference in stage of disease, tumour size, recurrence rates or survival between the two groups.3 It was postulated that breast implants may facilitate palpation of tumours and make the breast easier to examine, explaining why lesions of the same size were more frequently palpable in patients with implants.3 This explanation fits with our clinical experience, but there are other possible reasons for the higher rates of invasive tumours and axillary nodal metastases in this group. These explanations relate to the higher likelihood of a false-negative mammogram result in women with implants who do have regular screening, and to the lower rate of screening in women with implants because of reluctance to have mammograms for fear of damaging the implants.

The discrepancy between the higher rates of invasive tumours and axillary node metastases among women who have had breast augmentation on the one hand, and a lack of significant differences in cancer staging between women with and without breast implants on the other, may be explained, in part, by methodological limitations. These include use of the χ2 test, which may not have enough power to detect trends, and lack of consideration of confounding factors, such as age. According to a systematic review of observational studies, women with breast implants who develop breast cancer have later-stage tumours at diagnosis, while meta-analysis of these studies suggested that these women may also have an increased risk of non-localised breast tumours and lower rates of breast cancer-specific survival.4 The authors noted the need for further research to clarify the impact of breast augmentation on cancer detection and prognosis.

What is clear is that patients with breast implants present specific challenges for radiologists involved in breast imaging. Breast implants are radio-opaque and restrict the visualisation of breast tissue with mammography.4 Implants can also compress breast tissue, which can limit detection of subtle findings such as architectural distortion and microcalcifications. Twenty-six experts from five countries reviewed the best available evidence and concluded in a consensus statement that preoperative breast imaging, with mammography and/or ultrasound, should be considered essential, except in rare circumstances, before any breast augmentation procedure.5 Appropriate imaging may vary depending on the woman’s age, risk factors for breast cancer, breast density and clinical examination findings, but would usually involve mammography, possibly ultrasound and sometimes magnetic resonance imaging.

Failure to provide appropriate imaging not only has serious implications for the woman herself, but also for the health system, which is left paying for expensive surgery and adjuvant therapies that may have been avoided had the cancer been detected earlier, as a recent case from our practice demonstrates (Box 1). This case highlights the serious consequences of a probable missed opportunity to diagnose breast cancer 6 months earlier, when the disease most likely would have been entirely in situ. There are two implications for clinical practice. First, thorough clinical examination and risk assessment, as well as appropriate imaging, should become a routine component of the preoperative work-up for women who undergo breast augmentation. Second, if a general practitioner is aware of a patient’s intent to undergo breast augmentation, in Australia or overseas (given the increase in medical tourism), he or she should inform the patient of the importance of preoperative screening and arrange the appropriate imaging.

As a result of such cases, Breast Surgeons of Australia and New Zealand has developed a position statement on preoperative assessment of women who undergo breast surgery, which outlines the consensus view of what imaging is appropriate for different categories of women.2 The recommendations are summarised in Box 2.