HHS Public Access Author manuscript Author Manuscript
Br J Haematol. Author manuscript; available in PMC 2017 August 01. Published in final edited form as: Br J Haematol. 2016 August ; 174(3): 480–483. doi:10.1111/bjh.13779.
Breast implants and anaplastic large cell lymphomas among females in the California Teachers Study cohort Sophia S. Wang1,+, Dennis Deapen2, Jenna Voutsinas1, James V. Lacey Jr.1, Yani Lu1, Huiyan Ma1, Christina A. Clarke3, Dennis Weisenburger4, Stephen Forman5, and Leslie Bernstein1 1Division
Author Manuscript
of Cancer Etiology, Department of Population Sciences, City of Hope and the Beckman Research Institute, Duarte, California
2Division 3Cancer
of Preventive Medicine, University of Southern California, Los Angeles, California Prevention Institute of California, Fremont, California
4Division
of Hematology, City of Hope Medical Center, Duarte, California
5Division
of Pathology, City of Hope Medical Center, Duarte, California
Keywords anaplastic large cell lymphoma; T-cell; epidemiology; implants; breast
Author Manuscript Author Manuscript
Clinical case series have reported an apparent coexistence of breast implants and primary Tcell lymphomas of the breast, specifically for the anaplastic large cell lymphoma (ALCL) subtype (Gidengil et al 2015; Jewell et al 2011; Thompson & Prince 2013). In 2011, the Food and Drug Administration (FDA) reported a “possible association between breast implants and the development of ALCL” and encouraged “additional evaluation from other studies” (United States Food and Drug Administration 2011), particularly as epidemiological data have not yielded consistent results. A review of five prospective cohort studies comprising >43,000 women with cosmetic breast implants followed for up to 37 years found no excess ALCL risk (Lipworth et al 2008) . Data from a Danish cohort of approximately 20,000 women with breast implants identified 31 lymphomas, but no ALCLs Vase et al 2013) . Another study of >150,000 women with breast implants identified 3 breast ALCL, which was lower than expected based on cancer registry data [Spear et al (2010)] . However, a case-control study nested within the population-based cancer registry in the Netherlands with case ascertainment from 1994-2006, reported an association between silicone breast implants and ALCL (Odds Ratio [OR]=18.2, 95% Confidence Interval [CI]=2.1-156.8, based on 11 ALCLs).
+ To whom correspondence should be addressed: Sophia S. Wang, Ph.D., Division of Cancer Etiology, Department of Population Sciences, Beckman Research Institute and the City of Hope, 1500 East Duarte Road, Duarte, CA 91010, Phone: (626) 471-7316, FAX: (626) 471-7308, [email protected]. Authorship acknowledgments: S.S.W., J.V.L., Jr., L.B. conceived the study; S.S.W., D.D., Y.L., H.M., C.A.C., D.W., L.B. performed the research; S.S.W., J.V.L., Jr., L.B., S.F. designed the research study; J.V., S.S.W., L.B., J.V.L., Jr. analysed the data; S.S.W., D.D., J.V., J.V.L., Jr., Y.L., H.M., C.A.C., D.W., S.F., L.B. wrote the paper.
Wang et al.
Page 2
Author Manuscript
Here, we evaluated the association between breast implants and incident T-cell lymphomas in the California Teachers Study (CTS) cohort, a prospective cohort study comprising 133,479 female public school professionals who enrolled in 1995-1996 (www.calteachersstudy.org). This analysis included 123,392 women, after excluding those with a previous diagnosis of haematological cancer, those who were not California residents at baseline, and those who only wished to participate in breast cancer studies. The use of human subjects in this study was approved by each participating institution.
Author Manuscript
In 1995-96, CTS participants were asked whether they ever had breast implants, their age at first breast implant, and the type of implant inserted (e.g., silicone gel, saline). The CTS cohort is followed annually for cancer diagnosis through linkages with the California Cancer Registry, which receives information on >99% of all cancer diagnoses occurring in California residents. Non-Hodgkin lymphomas (NHLs) were defined using International Classification of Diseases for Oncology, Third Edition (ICD-O-3) morphology codes Fritz et al 2013). Between 1 January 1995 and 31 December 2012, 89 women were identified with incident T-cell lymphomas; the definition and distribution of the subtypes are shown in Table I.
Author Manuscript
We fitted multivariate Cox proportional hazards regression models to estimate the relative risk (hazard ratio, HR) of T-cell lymphoma and subtypes associated with breast implants and the 95% CIs for the relative risk. Age (in days) was the time scale used for the analysis. Follow-up began on the date the enrolment questionnaire was submitted and ended on the first of any of the following events: diagnosis of any haematological malignancy (NHL, Hodgkin lymphoma [HL], multiple myeloma, leukaemia), relocation outside of California, death, or 31 December 2012 (end of follow-up). All models were stratified by age (in years) at cohort entry, and initially adjusted for race (non-Hispanic, white, other), family history of HL or NHL, socioeconomic status, smoking status and body mass index (Supplemental Table 1). Because these variables modified the HR by
Br J Haematol. Author manuscript; available in PMC 2017 August 01. Published in final edited form as: Br J Haematol. 2016 August ; 174(3): 480–483. doi:10.1111/bjh.13779.
Breast implants and anaplastic large cell lymphomas among females in the California Teachers Study cohort Sophia S. Wang1,+, Dennis Deapen2, Jenna Voutsinas1, James V. Lacey Jr.1, Yani Lu1, Huiyan Ma1, Christina A. Clarke3, Dennis Weisenburger4, Stephen Forman5, and Leslie Bernstein1 1Division
Author Manuscript
of Cancer Etiology, Department of Population Sciences, City of Hope and the Beckman Research Institute, Duarte, California
2Division 3Cancer
of Preventive Medicine, University of Southern California, Los Angeles, California Prevention Institute of California, Fremont, California
4Division
of Hematology, City of Hope Medical Center, Duarte, California
5Division
of Pathology, City of Hope Medical Center, Duarte, California
Keywords anaplastic large cell lymphoma; T-cell; epidemiology; implants; breast
Author Manuscript Author Manuscript
Clinical case series have reported an apparent coexistence of breast implants and primary Tcell lymphomas of the breast, specifically for the anaplastic large cell lymphoma (ALCL) subtype (Gidengil et al 2015; Jewell et al 2011; Thompson & Prince 2013). In 2011, the Food and Drug Administration (FDA) reported a “possible association between breast implants and the development of ALCL” and encouraged “additional evaluation from other studies” (United States Food and Drug Administration 2011), particularly as epidemiological data have not yielded consistent results. A review of five prospective cohort studies comprising >43,000 women with cosmetic breast implants followed for up to 37 years found no excess ALCL risk (Lipworth et al 2008) . Data from a Danish cohort of approximately 20,000 women with breast implants identified 31 lymphomas, but no ALCLs Vase et al 2013) . Another study of >150,000 women with breast implants identified 3 breast ALCL, which was lower than expected based on cancer registry data [Spear et al (2010)] . However, a case-control study nested within the population-based cancer registry in the Netherlands with case ascertainment from 1994-2006, reported an association between silicone breast implants and ALCL (Odds Ratio [OR]=18.2, 95% Confidence Interval [CI]=2.1-156.8, based on 11 ALCLs).
+ To whom correspondence should be addressed: Sophia S. Wang, Ph.D., Division of Cancer Etiology, Department of Population Sciences, Beckman Research Institute and the City of Hope, 1500 East Duarte Road, Duarte, CA 91010, Phone: (626) 471-7316, FAX: (626) 471-7308, [email protected]. Authorship acknowledgments: S.S.W., J.V.L., Jr., L.B. conceived the study; S.S.W., D.D., Y.L., H.M., C.A.C., D.W., L.B. performed the research; S.S.W., J.V.L., Jr., L.B., S.F. designed the research study; J.V., S.S.W., L.B., J.V.L., Jr. analysed the data; S.S.W., D.D., J.V., J.V.L., Jr., Y.L., H.M., C.A.C., D.W., S.F., L.B. wrote the paper.
Wang et al.
Page 2
Author Manuscript
Here, we evaluated the association between breast implants and incident T-cell lymphomas in the California Teachers Study (CTS) cohort, a prospective cohort study comprising 133,479 female public school professionals who enrolled in 1995-1996 (www.calteachersstudy.org). This analysis included 123,392 women, after excluding those with a previous diagnosis of haematological cancer, those who were not California residents at baseline, and those who only wished to participate in breast cancer studies. The use of human subjects in this study was approved by each participating institution.
Author Manuscript
In 1995-96, CTS participants were asked whether they ever had breast implants, their age at first breast implant, and the type of implant inserted (e.g., silicone gel, saline). The CTS cohort is followed annually for cancer diagnosis through linkages with the California Cancer Registry, which receives information on >99% of all cancer diagnoses occurring in California residents. Non-Hodgkin lymphomas (NHLs) were defined using International Classification of Diseases for Oncology, Third Edition (ICD-O-3) morphology codes Fritz et al 2013). Between 1 January 1995 and 31 December 2012, 89 women were identified with incident T-cell lymphomas; the definition and distribution of the subtypes are shown in Table I.
Author Manuscript
We fitted multivariate Cox proportional hazards regression models to estimate the relative risk (hazard ratio, HR) of T-cell lymphoma and subtypes associated with breast implants and the 95% CIs for the relative risk. Age (in days) was the time scale used for the analysis. Follow-up began on the date the enrolment questionnaire was submitted and ended on the first of any of the following events: diagnosis of any haematological malignancy (NHL, Hodgkin lymphoma [HL], multiple myeloma, leukaemia), relocation outside of California, death, or 31 December 2012 (end of follow-up). All models were stratified by age (in years) at cohort entry, and initially adjusted for race (non-Hispanic, white, other), family history of HL or NHL, socioeconomic status, smoking status and body mass index (Supplemental Table 1). Because these variables modified the HR by
