What is the impact of breast augmentation on the Breast Screening Programme?

R. James l. Colville, Carole A. Mallen, Lesley McLean and Neil R. McLean

Department of Plastic Surgery, The Breast Screening Unit, Royal Victoria Infirmary, Newcastle Upon Tyne, UK

Aims: To identify the number of women with breast implants in the Newcastle Breast Screening Programme, it's additional workload and compare the number of screen detected cancers in the implant and non-implant group.

Methods: Retrospective 9 year review of all women with cosmetic breast augmentation who have joined the National Breast Screening Programme in Newcastle.

Results: The percentage of total screened attendances involving implants has increased from 61 (0. 10%) in 199093 to 97 (0.14%) in 1993-96 and 135 (0.23%) in 199699. Despite this increasing workload, no additional resources have yet been required in the Breast Screening Unit.

1209 cancers (0.57%) were found in the screened population, and there were no screen detected cancers in the implant group, and there was no significant difference between the groups.

Conclusions: As the number of younger women receiving breast implants continues to rise, when they become eligible for the National Health Service Breast Screening Programme (NHSBSP), departments should be aware that additional personnel and finance will be needed.

2003 Elsevier Science Ltd. All rights reserved.

Key words: breast implants; breast screening; workload; carcinomas.

Introduction

Screening mammography is more difficult and time consuming for women with breast implants because, manual exposures have to be set and different compression techniques are used to minimise the volume of breast tissue obscured by the implant.1,2 These facilities are not usually available in mobile screening units. Women with implants require 2 views (medio-lateral oblique and craniocaudal) at each visit, compared to the norm of 2 views at the first visit, and one subsequently, although from 2003, both views will be standard for all women. Women with implants may find the procedure uncomfortable and it is also time consuming, taking 15 minutes per examination, rather than the usual 5 min.

There are no figures in the UK for numbers of women with implants in the screening programme and how they impact on the resources of a breast screening unit. As a varying amount of breast tissue is obscured by the implant, it may be more difficult to identify screen detected cancers in this particular group.3,4

The purpose of this paper was to identify the number of women with breast implants screened as part of the National Health Service Breast Screening Programme (NHSBSP) in the Newcastle breast screening unit from 1990 to 99, to assess the impact on the working practice of the unit and to find the number of screen detected breast cancers in the implant group.

Methods and Materials

All screened women were identified from the computerised records at the Newcastle Breast Screening Unit from 1990 to 99, and the records and mammograms of those with unilateral or bilateral breast augmentation were reviewed. Women were excluded if the implant was a post mastectomy breast reconstruction, (because only the other breast is screened), if they were outside the routine scrdening age (5064 years old), their films were missing, they had moved from the region with their films or the implants had been removed prior to joining the programme. Therefore those included in the study were women between 50 and 64 years old who had undergone cosmetic breast augmentation. All women were invited every 3 years for screening, however some of the implant group were screened more often, as part of the MRC Frequency of Breast Screening Trial in which women in the study arm were screened annually between 1990-95. Each visit was counted as one attendance and the 9-year period (1990-99) was divided into 3 year intervals.

The results were presented as the number of attendances involving implants over the 3 year interval and also as a proportion of total attendances involving implants.

The number of screen detected tumours in each group were identified from the computerised data and the mammograms.

Data Anaysis

Data were analysed by the Department of Statistics at the University of Newcastle, using the Poisson distri bution and statistical significance was accepted if P < 0.05.

Results

From 1990 to 99, 215 women with breast implants were screened, of which 38 were excluded, (6 breast reconstructions, 4 younger than 50 years DId, 3 had implants removed, I transsexual, 7 films not found, 4 moved out of the region, 3 did not attend). 177 women had 350 implants; 4 had unilateral implants for asymmetry and the remainder were bilateral. The mean age of the women was 52.0 years (range 5064) and the average length of time from implant placement to joining the programme was 13.6 years (2 months30 years).

In the study period 1990-99, there were a total of 210 682 screening attendances of which the 177 women with implants made 293 atcendances. The number of attendances of this group of women and their percentage of the total attendances has increased yearly from 1990 to 1999, (Figs. I and 2) and is anticipated to rise even higher during the next round of screening 1999-2002.

The increased workload has had no impact on medical and radiographic personnel to date, and there have been no specific increased costings identified by the Breast Unit. It has been estimated that it cost around £2800 extra in 1999 alone to screen those women with breast implants, based on £30 for single view mammograms of both breasts charged in a non-profit making private hospital, but does not include additional staffing costs.

In the period 1990-99, there were 1209 screen detected breast cancers, (5.7 per 1000 women screened). No cancers- were found in the women with implants, but this was not significant (p = 0.13), and there were no interval cancers picked up in this group.

Discussion

Women with breast implants need to be identified early and redirected to a hospital screening service for manually set exposures and immediate processing, which takes three times as long as a routine mammogram 15 vs. 5 min There has been a linear increase in the number of attendances of women with implants aged 50-64 years in the screening programme from 1990 to 99. This is less than the total number of screened women with implants, because women outside this age range, were not recorded accurately on computer and were excluded. The percentage of attendances involving implants has also risen, nevertheless, the numbers are still small and have not yet had an impact on personnel or financial resources. The additional costs for this group have not been calculated by the Department, but a rough estimate of £30 extra per woman has been made for additional films and processing. This extra cost (£2,800) was about 0.3% of the Breast Unit's annual budget in 1999.

The National Implant Registry (NIR)3 has recorded a rise in the number of cosmetic breast augmentations performed annually from 1995 to 1999 in the UK (Fig. 3) and as the number of women entering the NHSBSP grows, increasing resources will probably be required.

Breast cancers detected in all screened patients in the Newcastle Breast Unit 1990-99 were 5.7 per 1000 women, which is within the national target. Over the same period, no patients with implants have had a cancer detected, and no interval cancers have developed, suggesting that screening has not missed any tumours. There is no significant difference in pickup rates between the two groups, because the implant group is too small to be of statistical significance (p=0.13). = 0. 3).

Deapen4 in a large retrospective series compared women with and without implants and found no difference in breast cancer detection rate or staging at diagnosis between the two groups. The study even suggested that augmented women had a lower risk of breast cancer, probably due to a smaller volume of breast tissue. Silverstein,5 however, in a similar sized series, concluded that implant women had a poorer pickup rate and a worse prognosis.

Conclusion

The number of women with breast implants joining the NHSBSP in Newcastle have increased steadily over the period 1990-99, but the growing workload has not impacted on the practice or budgeting of the Breast Screening Unit to date. National figures have shown that the number of women receiving implants continues to rise yearly and as they enter the screening programme, Breast Units around the country need to be aware of the problems posed by this group and make appropriate provisions for staffing and funding.

Acknowledgements

We would like to thank Professor J.N.R. Matthews, Department of Statistics, University of Newcastle for the data analysis. No grant has been received for this study.

References.