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Effect of Breast Augmentation on the Accuracy of Mammography and Cancer Characteristics

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Effect of Breast Augmentation on the Accuracy of Mammography and Cancer Characteristics ORIGINAL CONTRIBUTION Effect of Breast Augmentation on the Accuracy of Mammography and Cancer Characteristics Diana L. Miglioretti, PhD Context Breast augmentation is not associated with an increased risk of breast can- Carolyn M. Rutter, PhD cer; however, implants may interfere with the detection of breast cancer thereby de- Berta M. Geller, EdD laying cancer diagnosis in women with augmentation. Objective To determine whether mammography accuracy and tumor characteris- Gary Cutter, PhD tics are different for women with and without augmentation. William E. Barlow, PhD Design, Setting, and Participants A prospective cohort of 137 women with aug- Robert Rosenberg, MD mentation and 685 women without augmentation diagnosed with breast cancer be- tween January 1, 1995, and October 15, 2002, matched (1:5) by age, race/ethnicity, Donald L. Weaver, MD previous mammography screening, and mammography registry, and 10533 women Stephen H. Taplin, MD with augmentation and 974915 women without augmentation and without breast Rachel Ballard-Barbash, MD, MPH cancer among 7 mammography registries in Denver, Colo; Lebanon, NH; Albuquer- que, NM; Chapel Hill, NC; San Francisco, Calif; Seattle, Wash; and Burlington, Vt. Patricia A. Carney, PhD Main Outcome Measures Comparison between women with and without aug- Bonnie C. Yankaskas, PhD mentation of mammography performance measures and cancer characteristics, in- Karla Kerlikowske, MD cluding invasive carcinoma or ductal carcinoma in situ, tumor stage, nodal status, size, grade, and estrogen-receptor status. REAST AUGMENTATION IS THE Results Among asymptomatic women, the sensitivity of screening mammography based third most common type of on the final assessment was lower in women with breast augmentation vs women with- plastic surgery performed for out (45.0% [95% confidence interval {CI}, 29.3%-61.5%] vs 66.8% [95% CI, 60.4%- cosmetic reasons in the United 72.8%]; P=.008), and specificity was slightly higher in women with augmentation (97.7% [95% CI, 97.4%-98.0%] vs 96.7% [95% CI, 96.6%-96.7%]; PϽ.001). Among symp- BStates, with 268888 procedures in 1 tomatic women, both sensitivity and specificity were lower for women with augmen- 2002. In 2 studies conducted in the late tation compared with women without but these differences were not significant. Tu- 1980s, between 3.3 and 8.1 per 1000 mors were of similar stage, size, estrogen-receptor status, and nodal status but tended women reported ever having breast im- to be lower grade (P=.052) for women with breast augmentation vs without. 2,3 plants. Although breast implants have Conclusions Breast augmentation decreases the sensitivity of screening mammog- not been found to be associated with raphy among asymptomatic women but does not increase the false-positive rate. De- an increased risk of breast cancer,4,5 im- spite the lower accuracy of mammography in women with augmentation, the prog- plants may interfere with routine mam- nostic characteristics of tumors are not influenced by augmentation. mography evaluation; therefore, women JAMA. 2004;291:442-450 www.jama.com with breast augmentation may be more likely to be diagnosed with advanced mammography was uncommon26 and augmentation.4,7 Brinton et al4 found disease.6-16 Previous studies of breast radiologists did not use implantation women with breast implants (N=78) cancer following breast augmentation displacement views, a technique that tended to have later-stage disease com- have typically had small study samples improves visualization of breast tissue pared with women without augmenta- and yield conflicting results as to in women with implants.12 Author Affiliations and Financial Disclosure are listed whether breast implants delay cancer Two recent larger studies of breast at the end of this article. diagnosis.4,7,8,16-25 In addition, these stud- cancer following augmentation mam- Corresponding Author and Reprints: Diana L. Miglioretti, PhD, Center for Health Studies, Group ies include cancers diagnosed in the moplasty suggest breast cancer diag- Health Cooperative, 1730 Minor Ave, Suite 1600, Se- early 1980s when routine screening nosis may be delayed in women with attle, WA 98101 (e-mail: [email protected]). 442 JAMA, January 28, 2004—Vol 291, No. 4 (Reprinted) ©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 BREAST AUGMENTATION AND ACCURACY OF MAMMOGRAPHY tion (35% vs 17% with regional or dis- tic mammography examinations per- their index examination was within 2 tant disease); however, this difference formed in defined catchment areas. To years of diagnosis, whether the index was not statistically significant. Skin- determine cancer status and tumor examination was a first or subsequent ner et al7 found that mammography was characteristics, each mammography mammogram, and mammography reg- less sensitive for women with augmen- registry links to a state cancer registry istry. Women with augmentation were tation (N=99) compared with women (CMAP, CMR, NHMN, VBCSS) or re- also more likely to have dense breasts, without augmentation (66.3% vs gional Surveillance, Epidemiology, and have a family history of breast cancer, 94.6%) and that women with augmen- End Results program (GHC, NMMP, and be premenopausal or taking hor- tation were more likely to be diag- SFMR). Some registries additionally mone therapy; however, we did not nosed with palpable tumors (83% vs link to pathology databases (CMR, match by these variables as they were 59%), invasive carcinoma (82% vs GHC, NHMN, NMMP, VBCSS). Can- missing for 13% to 24% of women. In- 72%), and to have nodal involvement cer ascertainment from these com- stead, we did a sensitivity analysis by (48% vs 36%). Although both studies bined sources is estimated to be more adjusting for these variables to see if the were relatively large compared with ear- than 94.3% complete.28 Each registry results changed. lier studies, they also included breast has approval from its institutional re- The sensitivity and specificity of cancers diagnosed in the early 1980s. view board to collect these data for mammography were based on a 1-year This study used recent prospective analysis. follow-up. For calculation of sensitiv- data from 7 US mammography regis- ity and specificity, we excluded mam- tries that participate in the Breast Can- Study Sample mograms occurring after December 31, cer Surveillance Consortium (BCSC)27 Women were included in analyses if 2000, to allow sufficient time to de- to examine the effect of breast augmen- they had a mammography examina- tect cancers in the year following a tation on mammography accuracy and tion between January 1, 1995, and Oc- mammogram. To calculate sensitivity, cancer characteristics. Because the ma- tober 15, 2002, and were consistent we also excluded mammograms occur- jority of women in the BCSC have un- about reporting the presence or ab- ring more than 1 year before cancer di- dergone routine screening mammog- sence of breast augmentation. We ex- agnosis. raphy during a time when displacement cluded women with a personal history views are standard of care for women of breast cancer (self-report or prior di- Measures and Definitions with augmentation, this large cohort agnosis in the cancer registry or pa- Demographic information and a self- can better answer the question of thology database); self-report of prior reported breast health history were ob- whether breast implants interfere with mastectomy or breast reconstruction, tained at the time of each mammogra- mammography and thereby delay can- or augmentation for only 1 breast (total phy examination that included birth cer detection among women with aug- of 5%); or women with an inconsis- date, race, ethnicity, current symp- mentation. tent reporting of breast augmentation toms, breast augmentation status, his- once augmentation was first reported tory of mastectomy or breast recon- METHODS (eg, augmentation reported at 1 exami- struction, family history of breast Data Sources nation and no augmentation reported cancer, menopausal status, current Women were selected from 7 mam- at a future examination, Ͻ1%). The postmenopausal hormone therapy use, mography registries that form the Na- most recent mammography examina- and time since last mammography ex- tional Cancer Institute–funded BCSC, tion in the study period was desig- amination. Women were considered to which can be found at http://breast- nated the index examination. have breast augmentation if augmen- screening.cancer.gov.27 The 7 regis- Because women with breast augmen- tation was either self-reported on the tries were Carolina Mammography Reg- tation were younger, more likely to be questionnaire or indicated on the ra- istry (CMR), Chapel Hill, NC; Colorado white and non-Hispanic, and more diologist’s report. Women who re- Mammography Project (CMAP), Den- likely to have had a mammogram be- ported a breast lump or nipple dis- ver; Group Health Cooperative (GHC), fore the index examination, which may charge were considered to be Seattle, Wash; New Hampshire Mam- influence the sensitivity of mammog- symptomatic. Women were consid- mography Network (NHMN), Leba- raphy, and we had a limited number of ered to have a family history of breast non; New Mexico Mammography women with augmentation and breast cancer if they reported having at least Project (NMMP), Albuquerque; San cancer, we matched each woman with 1 female first-degree relative (mother, Francisco Mammography Registry augmentation and breast cancer to 5 sister, or daughter) with breast can- (SFMR), San Francisco, Calif; and Ver- women without augmentation but with cer. Women aged 55 years or older were mont Breast Cancer Surveillance Sys- breast cancer by age (plus or minus 3 assumed to be perimenopausal/ tem (VBCSS), Burlington. These years), race/ethnicity (white non- postmenopausal and those younger population-based mammography reg- Hispanic, black non-Hispanic, His- than 40 years were assumed to be pre- istries include screening and diagnos- panic, Asian, other), whether or not menopausal. Women aged 40 to 54 ©2004 American Medical Association. All rights reserved.
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