In the 1970s, a radical mastectomy represented the sole option for women with breast cancer. Years later, when the issue of quality of life was raised, the era of reconstructive surgery, via silicone gel breast implants--internal prostheses, was born. For the first time, women had the opportunity to recreate body symmetry and body integrity and in a sense reverse some of the horrors of mastectomy. There are various reasons for desiring breast implants--to feel whole again; to be less preoccupied with having breast cancer; to avoid the discomfort and awareness of an external prosthesis; to be able to wear more styles of clothes; to feel more feminine and sexually desirable. "The overwhelming motive, however, is to enhance one's body image, to increase self-esteem, and to improve quality of life," stated Wendy S. Schain, EDD, Psychosocial Director of Adult Oncology at the Memorial Cancer Institute in Long Beach, California, at the 11th Annual International Breast Cancer Meeting in Miami this past March.
The "Era of Terror"
"There are lots of reasons that women do want to have implants, and they ought to have the right for that option and be given the best information we have," Dr. Schain said. "Unfortunately, somewhere around 1988, Dr. Sidney Wolfe's consumer activist group started what ought to be known as the 'era of terror.' And women today are still being terrorized, not only by irresponsible media, but also by activists who are saying that this and that disease is being caused by implants, by lawyers, and by a few physicians who are charging inordinate fees for removal or modification of these devices."
Of course, there are certainly valid reasons for not seeking reconstructive surgery, including fear of promoting cancer recurrence and the expense incurred, and the possibility in a given woman, that implants might cause a serious problem; like a bee sting could cause a life-threatening shock reaction.
After breast implant surgery, some women have experienced physical difficulties, including breast pain, rupture, capsular contracture, joint pain, and fatigue. Although concrete data linking these problems to the implants have not been consistently documented, the value and safety of silicone implants have been questioned, perhaps in an attempt to identify a "problem-directed solution." The controversy surrounding the benefits versus the risks of such devices have become widely publicized, but substantive data regarding the psychological side effects of breast implant surgery have been underreported or minimized.
Although Dr. Schain acknowledged that for some women implants may "create, trigger, or promote some type of serious disease," she believes that most of the "psychological pain" reported by women with implants is a result of the irresponsible media, not by problems from the transudate of the gels themselves. Public sentiment and anecdotal reports have described the hazardous side effects of silicone gel breast implants, although the cause and effect have not been established through objective controlled clinical trials.
In an attempt to evaluate both sides of the implant controversy, one study out of Duke University referred to by Dr. Schain documented women's psychological reactions to the implant saga. Among the findings, 76% of the women questioned said the reconstruction helped them cope with cancer, whereas only 16% regretted they had undergone the reconstruction. In another related survey, 84% of the women who responded said the implants clearly improved their cosmetic appearance, 87% said they helped their emotional recovery, and 66% stated they improved their quality of life. Dr. Schain questioned whether the women's physical complaints and increased anxiety over them are actually linked to the implants themselves or the highly publicized controversy surrounding them.
The consensus of the various studies is that women with breast implants represent a very diverse group, with responses ranging from "I am going to buy a spare before they are banned in case I need one" to "I want to remove mine, I do not want to replace it, and I want to forget this experience." For women who desire explantation, psychological motives play a large part, especially if anxiety becomes overwhelming and the woman becomes obsessed with real or anticipated problems. In addition, for many women, even some women who have undergone mastectomy, motives have changed over the years. Priorities have shifted, and the devices may not best serve their needs any more. For women who desire breast implants, lengthy informed consents are essential. Alternative procedures as well as the risks/benefits of the reconstruction must be addressed.
"Neither the scientific community nor the public has a clear picture of the problems of women with implants," concluded Dr. Schain. Answers are needed to questions regarding the long-term safety and viability of these devices. Furthermore, the findings from various investigations must be disseminated responsibly.
"My friend Bill Little of Georgetown made a comment several years ago that I think is appropriate," Dr. Schain said. "He said that what we need in reference to breast reconstruction is the assurance that we have soft breasts and the accumulation of hard data. For too many years, unfortunately, we have had the converse--hard breasts and soft data."
A 70-year-old man with a history of localized prostate cancer treated with whole-pelvis radiation therapy with a boost to the prostate, in conjunction with androgen deprivation therapy 7 years prior, presented with lower back pain. A bone scan revealed an area of activity in the sacrum. What is the most likely diagnosis?
