Surgery is a common and effective means of treating breast cancer, used in some 95 percent of early stage breast cancer cases and 70 percent of later stage cases. Surgical options contribute to the current 89.7 percent five-year survival rate for all types of breast cancer as reported by the National Cancer Institute. However, these surgical procedures can leave patients with scars and a changed body shape and image. In response to these changes that may cause deep psychological pain for some patients, some will undergo breast reconstruction surgery. But as with just about all treatments for breast cancer, breast reconstruction surgery also offers the opportunity for side effects among those who’ve had implant-based breast reconstruction.
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There are a couple different ways to approach breast reconstruction. In what’s called an autologous breast reconstruction, the surgeon transplants fat and tissue from another part of the body to the breast area. This can be a big surgery that requires a lengthy recovery period, and it’s not the right option for everyone. Therefore, some patients who want to reconstruct the breast will have the other kind of reconstruction, one in which an implant — a balloon-shaped sac filled with either silicone or saline solution — is inserted behind the chest muscle to create the shape of a new breast.
How the body responds to these prosthetic implants is what causes capsular contracture, the most common side effect of implant-based reconstructive surgery. “Capsular contracture is quite common,” says Constance Chen, a board-certified breast surgeon based in New York. “It’s probably the most common complication following implant-based breast reconstruction.”
How Capsular Contracture Develops
Capsular contracture develops in some patients because the body is trying to protect itself from an object that’s been inserted that it recognizes as foreign. Every implant reconstruction offers the potential for the problem because “100 percent of breast implants will form a capsule around them,” Chen says. “That’s the way the body walls off the foreign body — the breast implant — from itself.” This capsule is made of scar tissue and in most patients, it’s soft and pliable and poses no problem. But in some patients, it can become hard and painful. It can also contract to change the shape and position of the reconstructed breast. When this happens, “then the implant needs to be removed or exchanged to solve the problem. Ideally, the entire capsule should also be removed so that there is no residual capsule in place,” Chen says.
Dr. Kenneth R. Lee, co-director of the aesthetic and reconstructive surgery institute at Orlando Health, says that removing the implant and the capsule that encases it fixes the immediate problem, but if the patient wants to again reconstruct the breast with another implant, the risk of recurrence of capsular contracture is higher. “It’s a tough situation to deal with for some patients,” he says.
Just how common capsular contracture is can be difficult to pin down, both because the diagnosis of the condition is fairly subjective (based on a visual and tactile grading scale rather than a blood test or other more precise diagnostic tool) and because much of the data on the condition has come from cosmetic augmentations rather than from breast cancer-related reconstructions. However, a 2008 study in the journal ePlasty looked at 112 breast cancer patients who’d undergone mastectomies and noted that “although surgical technique and the quality of breast prostheses have significantly improved over time, capsular contracture remains one of the most common complications associated with reconstructive breast surgery with an incidence ranging between 0.6 percent and 30 percent.” Further, a 2016 review article in the International Journal of Surgery Open also reported a wide variation in the incidence of capsular contracture. In looking at data from both cosmetic augmentations and post-mastectomy reconstructions, the authors of that 2016 review noted that “although a range from zero to 50 percent has been noted, a more realistic incidence for capsular contracture, would be between 8 percent and 15 percent.”
When you consider that the number of these procedures performed annually is on the rise, this condition could affect several thousand patients each year. A 2014 study examining trends and variations in the use of breast reconstruction in patients who’d undergone mastectomies in the United States that was published in the Journal of Clinical Oncology found that “reconstruction use increased from 46 percent in 1998 to 63 percent in 2007.” Data from the American Society of Plastic Surgeons found that in 2015, the number of breast reconstruction procedures performed after mastectomy for breast cancer in the United States grew 4 percent over the year prior to 106,300. That marks a rise of 35 percent since the year 2000.
[See: Breast Pain? Stop Worrying About Cancer.]
If you’ve had an implant-based reconstruction and notice a change in the appearance of the reconstructed breast or you notice that it becomes hard or painful to the touch, see your doctor right away. If it is capsular contracture, your doctor will grade the condition based on its severity using the Baker Scale of Capsular Contracture, named for James L. Baker, Jr., an Orlando-based plastic surgeon who devised the scale.The FDA reports the Baker scale has four levels:
— “Grade I: the breast is normally soft and looks natural
— Grade II: the breast is a little firm but looks normal
— Grade III: the breast is firm and looks abnormal (visible distortion)
— Grade IV: the breast is hard, painful, and looks abnormal (greater distortion)”
Chen says “in and of itself, capsular contracture is not dangerous. It does not cause disease or infection or cancer.” Lee adds that although there’s not an immediate disease risk, the constant pain that patients with later stage capsular contracture deal with could be considered a health problem.
Currently, there’s no real way to know ahead of time if a particular patient will develop capsular contracture. However, patients with a history of radiation treatments are much more likely to develop this condition, Lee says. “There are studies that show 75 percent of patients who’ve undergone radiation treatment get capsular contracture with an implant reconstruction.” This is likely because radiation can damage healthy cells that were in the field of radiation when the treatment was delivered. For these patients, either forgoing a reconstruction altogether or using an autologous tissue approach to build the new breast is often preferable to using implants.
Otherwise, specific risk factors for the condition haven’t been identified. “It appears to be idiopathic,” Lee says, meaning “we don’t really know why it occurs. There’s been some thought that it might be partially genetic, so, for example if multiple members of the family have had breast cancer and there’s multiple cases of capsular contracture among them,” the patient may have a higher risk. He says some doctors have also theorized that the condition could be the result of a “subclinical infection,” meaning an infection that doesn’t present with obvious symptoms but is still present. “No one knows if that’s true or not, but that’s one theory,” he says.
[See: What Not to Say to a Breast Cancer Patient.]
Chen says some patients are more prone to developing capsular contracture than others because their bodies are simply more reactive to trauma and create more scar tissue. When these patients undergo a second surgery to remove the problematic implant and capsule and have another one inserted, they “may form a new hard, painful capsule very quickly. In general, increased surgeries will also lead to increased scarring and thus may encourage more capsular contracture.”
Lee says there’s some evidence that massaging the implant starting about four weeks after the reconstruction may help keep the capsule more pliable. He also notes that an asthma drug called Accolate has “been shown in limited research to improve the capsule or at least prevent it from progressing,” but results have been mixed. Similarly, there’s some indication that using textured implants rather than smooth ones could reduce the risk of capsular contracture, but at the cost of a slightly elevated risk of developing anaplastic large cell lymphoma, a rare type of cancer that affects the immune system. “I don’t know that a lot of people actually believe that [textured implants reduce the incidence of capsular contracture] anymore, even though that was the early data,” Lee says. “These days, when you’re doing a reconstruction for breast cancer, textured implants are an extremely hard sell, because you’re telling a breast cancer patient she may have a higher risk of developing another type of cancer,” and many will select a different option just to be safe.
Currently, the only tried and true way to completely get rid of the problem is by removing the implant and the capsule that encases it, which means more surgery. And to completely avoid it, opt for an autologous breast reconstruction or forego reconstruction altogether.
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What Is Capsular Contracture? originally appeared on usnews.com
