Avery Nork, Kiren Chauhan, Brandel France de Bravo, MPH, National Center for Health Research

Is it safe to warm up food in plastic containers or using plastic wrap in the microwave or the oven?  In 2016, President Obama signed a law that strengthened the Toxic Substances Control Act that requires testing of chemicals to make sure they are safe. Prior to that law, more than 60,000 chemicals on the market had gone untested. With that enormous backlog, it may be decades before the EPA has tested the thousands of chemicals that are widely used today. So, let’s look into this issue more carefully.

What harmful chemicals, if any, does plastic have? Two major chemicals to watch out for are phthalates (used to soften plastics) and bisphenol A (BPA), which is used to make very hard, shatterproof plastic (it usually has #7 on the bottom) and is also found in the lining of canned foods and beverages. When phthalates and BPA get into our bodies, they affect estrogen or testosterone. BPA, phthalates, and other chemicals known as endocrine disruptors act like hormones in our body and affect our natural hormone production.  These types of chemicals have been linked to cancer, problems in the reproductive organs, and several other health problems.¹ In addition, a 2023 study found that children exposed to phthalates in the womb or during their first year of life were more likely to develop behavioral, attention, and learning disorders. That’s why six phthalates are banned by law from children’s products, and why the FDA is studying BPA to determine if it should be banned from baby bottles and the lining of food and beverage cans.

Plastic wrap has been ‘phthalate free’ since 2006, but in the United States it is made of polyvinyl chloride or PVC and contains a “plasticizer” called di(2-ethylhexyl)adipate or DEHA. DEHA is not a phthalate but is chemically very similar to the phthalate called DEHP.

Studies in the 1990s showed that DEHA can cause liver tumors in mice, and other studies showed that DEHA migrates from plastic wrap into food—particularly high fat foods such as cheese. A 1998 study by Consumers Union tested plastic-wrapped foods and found DEHA levels higher than what is recommended and even permitted by European advisory committees and regulatory agencies.² A 2014 study found DEHA in various cheeses as well as beef, chicken, and pork that was sold in clinging plastic wrap at grocery stores.³ A 2021 study found that DEHA triggered brain and heart injuries in rats, but research is needed to better understand the risks for humans.⁴

Similarly, high density polyethylene (HDPE) plastic containers, which are typically used to store household cleaners and pesticides but are sometimes used for food storage, tested positive for PFAS. The results of a 2023 experiment showed that PFAS were capable of transferring into food, and that if there are PFAS in your food storage, it will transfer into your food over time. The researchers tested olive oil, ketchup, and mayonnaise and found that all of them had detectable levels of PFAS after being in contact with an HDPE for a week. While HDPEs are currently not intended for food storage, there is nothing stopping plastic companies from using them that way. This could be potentially harmful to thousands of people by exposing them to high levels of PFAS.

“I don’t eat a lot of canned food and I don’t drink soda. Are there other ways that chemicals found in plastic could be getting into my food?”

Many foods are sold in plastic containers and most of us keep leftovers in food storage containers made out of plastic, such as Tupperware, Rubbermaid, other brands, as well as carryout containers from restaurants. While none of these containers seem to be made with phthalates (since those are usually relatively soft), some may have BPA. As companies have become more aware of the dangers of the plastics they were using, they replaced some chemicals with others. When we checked Rubbermaid’s website in 2023, it states that it currently makes no products with BPA or phthalates (if you want to see if any of your older Rubbermaid products contain BPA, check here). Tupperware says all of its products are BPA free as of 2010, but any older products still might contain levels of BPA. If you want to check if your Tupperware is BPA-free, check the bottom of the container. Any number 1 through 6 means it is BPA-free, but a 7 means there might be BPA in that product. In addition, the company that makes Saran Wrap changed the chemicals in its product, making it less clingy but less dangerous to our planet.⁵

Regardless of whether a plastic food container contains phthalates or BPA, it may not be entirely safe. Plastics break down over time, which means they can potentially release trace amounts of whatever chemicals they are made of into the food. This is more likely to happen when the plastic has been heated or when it’s old and has been subjected to repeated use or washings. In fact, numerous studies show that most, if not all, humans have microplastics in our bodies, often from the food and drinks we consume every day.⁶ Perhaps these chemicals are harmless, but there isn’t any research on the cumulative effect of constantly eating food stored or heated in these plastic containers. It would not be surprising to find out that they may not be as safe as many of us assumed.

So what about all that food we buy that says to microwave it in the plastic container it’s sold in?

That type of plastic is said to be “microwave safe,”, but this means it won’t melt in the microwave—it doesn’t mean that it won’t release small amounts of chemicals into your food. Anything not marked “microwave safe,” will soften and lose its shape in the microwave. “Take out” food containers or other disposable plastic food containers (like the ones that refrigerated foods such as soft cream cheese or butter are sold in) are especially unsafe to use in the microwave. In their study, Good Housekeeping researchers microwaved food in a variety of plastic containers labeled microwave safe and found no detectable levels of BPA (or phthalates) in most.⁷ But if your favorite containers have these chemicals, in addition to all the other ways you can be exposed to endocrine-disrupting chemicals and microplastics, you could end up with unhealthy levels of these chemicals in your body. Two Canadian environmentalists experimented on themselves for four days by exposing themselves to various chemicals found in food and beverage containers and other household objects and wrote a book called Slow Death by Rubber Duckie!

We need more research to know what plastics are safe—under what conditions and for what use. Until we have that information, you can “play it safe” and reduce the amount of chemicals getting into your food from plastic by following these tips:

• Avoid allowing plastic wrap to come into contact with food, especially when heating or if the food has a high fat content (like meat or cheese). If you want to prevent food from splattering in the microwave, cover it with a microwave-safe dish or a paper towel.

• Use glass or ceramic containers to microwave food and beverages, and avoid microwaving in plastic or disposable containers.⁸

• Although 96% of canned foods from major supermarkets that were tested in 2019 were BPA free, you might want to throw away older canned goods in your home that still might have BPA in the lining.⁹

• Look for drinks sold in cartons or glass. Some of the glass bottles may have lids lined with BPA, but even so, the top is not usually in contact with the beverage. If you carry a reusable water bottle, switch to stainless steel or make sure your sports bottle is “BPA-free.” [Do NOT re-use the kind of plastic bottles that bottled water is sold in, because they are not safe for repeated use.] Plastics that contain BPA are usually hard and make a clicking noise if you hit them with your fingernail or a fork or other metal utensil, and may have the number seven on the bottom.

Remember that all plastics break down when exposed to heat—whether in the microwave or dishwasher—and when exposed to strong soaps. Cracks and cloudiness are signs that a clear, reusable plastic container has started to break down and may be releasing BPA or other chemicals into your beverage or food.

All articles on our website have been approved by Dr. Diana Zuckerman and other senior staff.

References.

1. National Institutes of Health. (n.d.). https://deainfo.nci.nih.gov/advisory/pcp/annualReports/pcp08-09rpt/PCP_Report_08-09_508.pdf
2. Report to the FDA regarding plastic packaging. CR Advocacy. (n.d.). https://advocacy.consumerreports.org/press_release/report-to-the-fda-regarding-plastic-packaging/
3. Cao, X. L., Zhao, W., Churchill, R., & Hilts, C. (2014). Occurrence of Di-(2-ethylhexyl) adipate and phthalate plasticizers in samples of meat, fish, and cheese and their packaging films. Journal of food protection, 77(4), 610–620. https://doi.org/10.4315/0362-028X.JFP-13-380
4. Behairy, A., Abd El-Rahman, G. I., Aly, S. S. H., Fahmy, E. M., & Abd-Elhakim, Y. M. (2021). Di(2-ethylhexyl) adipate plasticizer triggers hepatic, brain, and cardiac injury in rats: Mitigating effect of Peganum harmala oil. Ecotoxicology and environmental safety, 208, 111620. https://doi.org/10.1016/j.ecoenv.2020.111620
5. Emma KumerUpdated: May 18, 2023. (2023, May 18). Is it just us, or is Saran wrap less sticky?. Taste of Home. https://www.tasteofhome.com/article/why-todays-saran-wrap-is-less-sticky/
6. Pinto-Rodrigues, A. (2023a, April 10). Microplastics are in our bodies. here’s why we don’t know the Health Risks. Science News. https://www.sciencenews.org/article/microplastics-human-bodies-health-risks
7. Is it safe to heat food in plastic?. Good Housekeeping. (2022, August 16). https://www.goodhousekeeping.com/institute/a17859/plastic-safety-heat-food/
8. Food Safety and Inspection Service. Cooking with Microwave Ovens | Food Safety and Inspection Service. (n.d.). https://www.fsis.usda.gov/food-safety/safe-food-handling-and-preparation/food-safety-basics/cooking-microwave-ovens
9. Canned Foods. Center for Environmental Health. (2020a, January 27). https://ceh.org/products/canned-foods/

An estimated 100,000 people live with liver cancer in the U.S.[1] with about 41,000 new cases each year.2 Although less common than many other cancers in the U.S., the rate of newly diagnosed liver cancer has tripled since 1980 and death rates have doubled.[2]  It is often diagnosed in late stages and when it is, the average survival after diagnosis is less than 4 months at stage 4, compared to more than 3 years at the earliest stage.[3]

Early diagnosis and reducing the risks of developing liver cancer would save thousands of lives each year.  Research indicates that liver cancer disproportionality affects Asian American and Pacific Islander (AAPI) communities, which is the fasted growing racial and ethnic minority in the US.[4] Asian Americans are almost twice as likely to be diagnosed with liver cancer than Non-Hispanic White Americans, and in 2019, liver cancer was the sixth leading cause of death among 25-44 year old Asian Americans.[5] A better understanding of those disparities could save many lives.

This article will explain the signs and symptoms of liver cancer and the steps you can take to prevent it. 

Symptoms and Outcomes of Liver Cancer

Many symptoms of liver cancer are also symptoms of liver damage, [6]which can include:

• Jaundice (yellowing of the skin or the whites of the eyes)
• Pain in the right abdomen or shoulder blade
• Lump in your right abdomen

However, liver cancer can also result in symptoms that are typical of other illnesses:[7]

• Weight or appetite loss
• Nausea or vomiting
• General weakness or fatigue 

Primary liver cancer refers to cancer that originates in the liver, and is usually a single large tumor, whereas liver cancer that originates from another region of the body but spreads to the liver is called liver metastases and usually consists of several small tumors.[6] Liver metastases are more common than primary liver cancer and may spread throughout the liver before they are detected, while primary liver cancer can cause symptoms very early.[6,8]

How can you prevent it? 

There are several things you can do to reduce your chances of developing primary liver cancer.

Get tested for Hepatitis C: Approximately half of all primary liver cancer can be attributed to a single cause: the Hepatitis C virus.[9] The virus causes inflammation to the liver, which can lead to scarring (or ‘cirrhosis’) and then ultimately to liver cancer. You can contract Hepatitis C by being in contact with the blood of an infected person, so injecting drugs. is the most common way the virus is spread in the U.S.[10] The virus may silently damage the livers of infected people for decades before any symptoms appear. In fact, about half of people with Hepatitis C don’t even know they are infected.[11] Of the 3.5 million Americans estimated to be infected with Hepatitis C, 81% are baby boomers who were likely infected before Hepatitis C was discovered in 1989.[9]

Since Hepatitis C often has no symptoms, it’s crucial to get tested. The CDC recommends that all adults get tested for Hepatitis C at least once in their life, and all pregnant women get tested during every pregnancy.[12] Persons who inject drugs or share needles should get tested regularly.[12]

Get vaccinated for Hepatitis B: Hepatitis B is thought to cause about 15% of Liver cancer cases in the U.S. Like Hepatitis C, Hepatitis B attacks the liver, and most people who have been infected don’t realize it.[13] While about 1 million more Americans are living with Hepatitis C than B,[13] Hepatitis B is 5-10 times more infectious and is most commonly spread from mother to child during birth.[14] It is also more commonly transmitted through sexual activity than Hepatitis C.[15] Fortunately, Hepatitis B can be prevented with a vaccine, while Hepatitis C currently cannot. The Hepatitis B vaccine is usually given as a series of 3 shots shortly after birth, 1-2 months after birth, and 6-18 months after birth.[16] As of 2022, the CDC recommends all unvaccinated children and adults age 19-59 receive the Hepatitis B vaccine.[17] 

Asian American and Pacific Islanders make up approximately half of all Americans currently infected with Hepatitis B, despite making up only 6% of the U.S. population. That is likely because Hepatitis B has circulated around many countries in East Asia, Southeast Asia, and the Pacific for thousands of years, and also because these regions have very low rates of infant Hepatitis B vaccinations.[18]

Get treated for Hepatitis B or C: There are many treatment options for chronic Hepatitis C that can reduce its viral load to an undetectable level and help prevent cancer-causing liver damage. Antiviral medications are one of the most common ways treat the virus. FDA has approved several antiviral medications for the treatment of either Hepatitis B or C in the US, and there continue to be new advances in treatment options. These antiviral medications may vary in terms of safety or effectiveness. For example,  information about two of the most widely used Hepatitis B antivirals (Baraclude and Vemildy) and Hepatitis C antivirals (Mavyret and Epclusa) are shown in the table below.[19,20] FDA has approved all these drugs as having benefits that outweigh the risks in treating Hepatitis B or C, but your doctor may suggest specific medications based on your Hepatitis diagnosis, preexisting conditions, and other health factors.

^ frequency not reported

Avoid alcohol and smoking: Alcohol is well known to damage the liver; an analysis of 112 studies found that consuming an average of just one alcoholic drink a day was associated with a 10% greater chance of developing liver cancer.[34] The annual average is of 9.5 new cases and 6.6 deaths from liver cancer for every 100,000 adults in the U.S.,[1] but a review of 28 studies that analyzed almost 5,000 new cases of liver cancer and more than 10,000 liver cancer deaths found that moderate and heavy drinkers (at least 1 drink/day for females and at least 2 drinks/day for males) were 42% more likely to be diagnosed with liver cancer and 17% more likely to die from it.[35] 

Smoking also significantly increases the chance of developing liver cancer. A 2018 study of more than 1 million Americans found that current smokers were 86% more likely to be diagnosed with liver cancer than non-smokers. Fortunately, the study also found that individuals who quit smoking at least 30 years ago had the same risk of liver cancer as those who had never smoked, suggesting that younger smokers who decide to quit smoking now can significantly reduce their future risk of developing liver cancer.

Maintain a healthy weight: Studies consistently show that being overweight or obese increases the risk of developing liver cancer;[36] In one analysis of 11 different studies, even after most studies controlled for the effects of age, sex, smoking, and other health conditions, being overweight (BMI between 25-30) increased the risk of liver cancer by 17%, while being obese (BMI 30 or above) increased the risk by 89%.[37] For example, one of the studies, of more than 780,000 Korean men, found a rate of liver cancer of 43 out of every 100,000 for men with a healthy weight (BMI 18.5-25), compared to 66 for every 100,000 for men who were obese.[38] This may be because fat tissue that accumulates in the liver can cause damaging inflammation, which may then lead to liver cancer.[36]

Taking steps to maintain a healthy weight through diet and exercise can therefore reduce the chances of developing liver cancer. An important question is whether losing weight through bariatric surgery also reduces the chances of developing liver cancer.[36] For example, in a study of 190 morbidly obese individuals with non-alcoholic steatohepatitis (a type of fatty liver disease that increases the risk of liver cancer), 85% were rid of the disease one year after bariatric surgery.[39] However, more long-term research is needed to investigate whether bariatric surgery reduces the risk of liver cancer or whether other factors are influencing those better outcomes.[36] For example, in a 2022 study, more than 5,000 adults with obesity who received bariatric surgery and more than 25,000 patients who received nonsurgical care were followed for an average of 6 years. While bariatric surgery patients had a lower rate of liver cancer (9 versus 15 cases per 100,000 people per year), this difference was not statistically significant when adjusted for other factors such as age, sex, smoking status, and medication use.[40]  That means that the differences were probably due to those other traits, not to the bariatric surgery itself.

References:

1. Cancer of the Liver and Intrahepatic Bile Duct – Cancer Stat Facts. SEER. Accessed August 4, 2022. https://seer.cancer.gov/statfacts/html/livibd.html
2. Key Statistics About Liver Cancer. Accessed August 4, 2022. https://www.cancer.org/cancer/liver-cancer/about/what-is-key-statistics.html
3. Survival | Liver cancer | Cancer Research UK. Accessed August 9, 2022. https://www.cancerresearchuk.org/about-cancer/liver-cancer/survival
4. Budiman A, Ruiz NG. Key facts about Asian Americans, a diverse and growing population. Pew Research Center. Published 2021. Accessed December 16, 2021. https://www.pewresearch.org/fact-tank/2021/04/29/key-facts-about-asian-americans/
5. Chronic Liver Disease and Asian Americans – The Office of Minority Health. Accessed August 4, 2022. https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=47
6. The Warning Signs of Liver Cancer. Verywell Health. Accessed August 4, 2022. https://www.verywellhealth.com/liver-cancer-symptoms-514170
7. Liver cancer – Symptoms and causes. Mayo Clinic. Accessed August 4, 2022. https://www.mayoclinic.org/diseases-conditions/liver-cancer/symptoms-causes/syc-20353659
8. Lee S. Liver metastases. Canadian Cancer Society. Accessed August 4, 2022. https://cancer.ca/en/cancer-information/cancer-types/metastatic/liver-metastases
9. Viral Hepatitis and Liver Cancer. Published online 2016:3.
10. Policy (OIDP) O of ID and H. Hepatitis C Basic Information. HHS.gov. Published April 10, 2016. Accessed August 5, 2022. https://www.hhs.gov/hepatitis/learn-about-viral-hepatitis/hepatitis-c-basics/index.html
11. Hepatitis C – Symptoms and causes. Mayo Clinic. Accessed August 5, 2022. https://www.mayoclinic.org/diseases-conditions/hepatitis-c/symptoms-causes/syc-20354278
12. Schillie S. CDC Recommendations for Hepatitis C Screening Among Adults — United States, 2020. MMWR Recomm Rep. 2020;69. doi:10.15585/mmwr.rr6902a1
13. Policy (OIDP) O of ID and H. Viral Hepatitis in the United States: Data and Trends. HHS.gov. Published April 20, 2016. Accessed August 5, 2022. https://www.hhs.gov/hepatitis/learn-about-viral-hepatitis/data-and-trends/index.html
14. What’s the Difference: Hepatitis B vs Hepatitis C? Hepatitis B Foundation. Published January 9, 2019. Accessed August 5, 2022. https://www.hepb.org/blog/whats-the-difference-hepatitis-b-vs-hepatitis-c/
15. Sexual Transmission and Viral Hepatitis | CDC. Published April 22, 2021. Accessed August 5, 2022. https://www.cdc.gov/hepatitis/populations/stds.htm
16. CDC. Hepatitis B and the Vaccine (Shot). Centers for Disease Control and Prevention. Published August 2, 2019. Accessed August 5, 2022. https://www.cdc.gov/vaccines/parents/diseases/hepb.html
17. CDC. Hepatitis B – Vaccination of Adults | CDC. Centers for Disease Control and Prevention. Published March 28, 2022. Accessed August 5, 2022. https://www.cdc.gov/hepatitis/hbv/vaccadults.htm
18. hepbtalk. Hepatitis B in Asian Populations. Hepatitis B Foundation. Published December 23, 2020. Accessed August 5, 2022. https://www.hepb.org/blog/hepatitis-b-asian-populations/
19. Chen LP, Zhao J, Du Y, et al. Antiviral treatment to prevent chronic hepatitis B or C-related hepatocellular carcinoma. World J Virol. 2012;1(6):174-183. doi:10.5501/wjv.v1.i6.174
20. Hepatitis C Medications: A Full List. Healthline. Published May 4, 2022. Accessed August 10, 2022. https://www.healthline.com/health/hepatitis-c/full-medication-list
21. Entecavir Side Effects: Common, Severe, Long Term. Drugs.com. Accessed August 10, 2022. https://www.drugs.com/sfx/entecavir-side-effects.html
22. Hypoalbuminemia: Causes, Symptoms, Treatment & Outlook. Cleveland Clinic. Accessed August 12, 2022. https://my.clevelandclinic.org/health/diseases/22529-hypoalbuminemia
23. Thrombocytopenia (low platelet count) – Symptoms and causes. Mayo Clinic. Accessed August 12, 2022. https://www.mayoclinic.org/diseases-conditions/thrombocytopenia/symptoms-causes/syc-20378293
24. Durval A, Zamidei L, Bettocchi D, Luzzio MG, Consales G. Hyperlipidemic acute pancreatitis: a possible role of antiretroviral therapy with entecavir. Minerva Anestesiol. 2011;77(10):1018-1021.
25. Entecavir (Oral Route) Side Effects – Mayo Clinic. Accessed August 10, 2022. https://www.mayoclinic.org/drugs-supplements/entecavir-oral-route/side-effects/drg-20063656?p=1
26. Vemlidy Side Effects: Common, Severe, Long Term. Drugs.com. Accessed August 10, 2022. https://www.drugs.com/sfx/vemlidy-side-effects.html
27. Tenofovir Alafenamide (Oral Route) Side Effects – Mayo Clinic. Accessed August 10, 2022. https://www.mayoclinic.org/drugs-supplements/tenofovir-alafenamide-oral-route/side-effects/drg-20313020?p=1
28. Commissioner O of the. FDA approves treatment for adults and children with all genotypes of hepatitis C and compensated cirrhosis that shortens duration of treatment to eight weeks. FDA. Published March 24, 2020. Accessed August 5, 2022. https://www.fda.gov/news-events/press-announcements/fda-approves-treatment-adults-and-children-all-genotypes-hepatitis-c-and-compensated-cirrhosis
29. Mavyret Side Effects: Common, Severe, Long Term. Drugs.com. Accessed August 10, 2022. https://www.drugs.com/sfx/mavyret-side-effects.html
30. Mavyret side effects: What they are and how to manage them. Published July 27, 2022. Accessed August 10, 2022. https://www.medicalnewstoday.com/articles/drugs-mavyret-side-effects
31. Commissioner O of the. FDA Approves New Treatment for Pediatric Patients with Any Strain of Hepatitis C. FDA. Published March 24, 2020. Accessed August 5, 2022. https://www.fda.gov/news-events/press-announcements/fda-approves-new-treatment-pediatric-patients-any-strain-hepatitis-c
32. Epclusa Side Effects: Common, Severe, Long Term. Drugs.com. Accessed August 10, 2022. https://www.drugs.com/sfx/epclusa-side-effects.html
33. Epclusa: Side effects, for hepatitis C, dosage, and more. Published June 30, 2022. Accessed August 10, 2022. https://www.medicalnewstoday.com/articles/326248
34. Chuang SC, Lee YCA, Wu GJ, Straif K, Hashibe M. Alcohol consumption and liver cancer risk: a meta-analysis. Cancer Causes Control. 2015;26(9):1205-1231. doi:10.1007/s10552-015-0615-3
35. Park H, Shin SK, Joo I, Song DS, Jang JW, Park JW. Systematic Review with Meta-Analysis: Low-Level Alcohol Consumption and the Risk of Liver Cancer. Gut Liver. 2020;14(6):792-807. doi:10.5009/gnl19163
36. Saitta C, Pollicino T, Raimondo G. Obesity and liver cancer. Annals of Hepatology. 2019;18(6):810-815. doi:10.1016/j.aohep.2019.07.004
37. Larsson SC, Wolk A. Overweight, obesity and risk of liver cancer: a meta-analysis of cohort studies. Br J Cancer. 2007;97(7):1005-1008. doi:10.1038/sj.bjc.6603932
38. Oh SW, Yoon YS, Shin SA. Effects of Excess Weight on Cancer Incidences Depending on Cancer Sites and Histologic Findings Among Men: Korea National Health Insurance Corporation Study. JCO. 2005;23(21):4742-4754. doi:10.1200/JCO.2005.11.726
39. Lassailly G, Caiazzo R, Buob D, et al. Bariatric Surgery Reduces Features of Nonalcoholic Steatohepatitis in Morbidly Obese Patients. Gastroenterology. 2015;149(2):379-388; quiz e15-16. doi:10.1053/j.gastro.2015.04.014
40. Aminian A, Wilson R, Al-Kurd A, et al. Association of Bariatric Surgery With Cancer Risk and Mortality in Adults With Obesity. JAMA. 2022;327(24):2423-2433. doi:10.1001/jama.2022.9009

Diana Zuckerman, PhD, Cancer Prevention & Treatment Fund

In 2015, plastic surgeons who have been well known for defending the safety of breast implants published a study of 173 women with cancer of the immune system caused by breast implants. [1]   The study was paid for by a plastic surgery medical association and written by plastic surgeons who have defended the safety of breast implants for decades.

ALCL (Anaplastic Large Cell Lymphoma) develops near a breast implant but is not breast cancer – it is a cancer of the immune system.  The authors of this study point out that the first silicone breast implant was implanted in 1962 and the first publicly reported case of ALCL in a woman with silicone breast implants was in 1997. The authors reviewed 37 medical articles reporting on 79 patients and collected information about an additional 94 women with ALCL caused by breast implants.

Results

Physicians first identified these 173 women with ALCL based on either seromas (a collection of fluid under the skin), a mass attached to the scar capsule surrounding the implant, a tumor that eroded through the skin, in a lymph node near the breast, or discovered during surgery to replace a breast implant. Whether the women had silicone gel or saline breast implants didn’t seem to make a difference, but many of the women had at least one textured breast implant.  Cosmetic augmentation patients and women who had breast implants to reconstruct their breasts after undergoing a mastectomy were both at risk of developing ALCL because of their implants.  Of the women whose ALCL spread outside of their scar capsule surrounding the implant, about half died from ALCL.

The authors pointed out that ALCL can be difficult to diagnose.  Although the fluid and scar capsule usually appear abnormal, they sometimes look normal. The authors recommend “that all fluid and capsule tissue from patients with seromas” should be tested for ALCL.  They point out that if the tumor is inside the capsule, removing both implants and the capsules may be the only treatment necessary.  However, if the tumor has developed just outside the capsule, chemotherapy with or without radiation is needed and usually effective.  Unfortunately, aggressive ALCL that has spread beyond the scar capsule area is usually fatal, regardless of treatment.

2017 Update

In March 2017, the U.S. Food and Drug Administration (FDA) reported that it had received 359 reports of ALCL among women with breast implants. Unfortunately, many cases of ALCL are not reported to the FDA.  The FDA’s announcement came after the World Health Organization (WHO) officially named the disease “breast implant associated ALCL (BIA-ALCL)” in 2016. In 2014, the National Comprehensive Cancer Network (NCCN) has also released a worldwide oncology standard for surgeons and oncologists to test for and diagnose the disease.

To read the official summary of this article, click here: http://www.ncbi.nlm.nih.gov/pubmed/25490535

To read about another study on ALCL, click here.

To read more about what you need to know about ALCL, click here.

Reference

1.  Brody GS, Deapen D, Taylor CR, Pinter-Brown L, House-Lightner SR, Andersen JS, Carlson G, Lechner MG, Epstein AL. Anaplastic Large Cell Lymphoma Occurring in Women with Breast Implants: Analysis of 173 Cases. Plastic and Reconstructive Surgery. Vol 135: 695, 2015.

Maura Duffy, Cancer Prevention & Treatment Fund

Experts now agree that breast implants can cause a type of cancer of the immune system.  The FDA finally admitted this risk of cancer in 2017, but other experts – including plastic surgeons — were aware of the risk years before.  Why did it take so long for FDA, the media, and women with implants to find out that choosing breast implants could increase their chances of developing a potentially fatal disease?

Anaplastic large cell lymphoma (ALCL) is a rare type of cancer of the immune system that usually develops in the lymph nodes, skin, lungs, or liver. However, ALCL sometimes develops in the breast area of women with breast implants.

In 2008 Dutch researchers published a report of 11 women with breast implants and ALCL, and concluded that the implants seemed to be associated with ALCL.[3]  Although published in the Journal of the American Medical Association (JAMA), this information was not widely reported.

The link between ALCL and breast implants was first reported by the FDA in January of 2011. In 2013, researchers at MD Anderson Cancer Center studied 60 women with breast implants who were diagnosed with ALCL in the breast. Since ALCL was thought to be diagnosed in only 1 woman in half a million, this was much higher than would be expected.[4]  In 2016, the World Health Organization (WHO) officially recognized BIA-ALCL.[5]  In 2017, the National Comprehensive Cancer Network (NCCN), a nonprofit network of cancer experts, released a worldwide oncology standard for surgeons and oncologists to test for and diagnose “breast implant associated ALCL (BIA-ALCL).” NCCN includes a guided algorithm for surgeons and oncologists to test for and diagnose the disease.  They concluded that any abnormal accumulation of fluid or a mass that develops near the breasts in women with breast implants must be evaluated.

And yet, it was not until March 2017 that the FDA finally updated its website to officially report that breast implants could cause ALCL. At the time of the FDA announcement, the agency reported that they had received 359 reports of ALCL among women with breast implants. Reports to the FDA of problems from medical devices are acknowledged to be the “tip of the iceberg” since surgeons frequently do not do these online reports.

How did women find out they had ALCL before the official announcement of BIA-ALCL was made? Most of them approached their doctors with symptoms such as pain, lumps, swelling, or asymmetry in their breasts years after getting implants.  Since breast implants are a “foreign body,” the body forms scar tissue around the implant to protect their body from this “foreign invader.”  The scar tissue surrounding the implant is known as the scar capsule. It is natural for the body to form scar tissue, and the scar tissue is only a problem if it tightens or hardens around the implants, causing pain and hardness known as “capsular contracture.”  Breast implant-associated ALCL is almost always found in the scar capsule surrounding the implant, not the breast tissue itself. It has been reported in women both with and without capsular contracture, as well as women with silicone gel or saline breast implants.[4]

ALCL is diagnosed by testing the fluid that collects around the implant, called a seroma.[5] Seroma is usually not caused by ALCL.  It is important to understand that even when ALCL is in the breast, it is not breast cancer, but rather a cancer of the immune system.  Most breast implant-associated ALCL has cancer cells within the fluid inside the scar capsule. That ALCL can be treated by removing the implant and the surrounding scar tissue. This surgery is known as a capsulectomy.

One study of nine women who had a capsulectomy after being diagnosed with BIA-ALCL found that all nine were disease free when they were studied 3.5 years later, and they did not require chemotherapy nor radiation treatment. However, some types of ALCL are more aggressive and need to be treated with chemotherapy or radiation. [6]

In December 2013, the study of 60 patients with breast implants and ALCL reported that the ALCL was more likely to be fatal for women who had a solid ALCL tumor than for women who had ALCL cancer cells in the surrounding fluid (known as effusion ALCL). All of the patients with effusion-type ALCL were still alive 5 years after their diagnosis, compared to only 75% of the patients with solid ALCL tumors. ALCL returned in only 14% of patients with effusion-type ALCL. Patients with solid ALCL tumors had a 50% recurrence rate.[7]

Longer studies with more patients are needed to determine if certain kinds of breast implants are more likely to cause ALCL.  Preliminary data indicate that most, but not all, women with BIA-ALCL had textured breast implants at some point.  Meanwhile, women with all types of implants should have routine follow-ups and should immediately see a doctor if one or both of their breasts become swollen.

For women with silicone implants, FDA recommends getting a breast coil MRI three years after getting the implants, and every two years after that.[8]

Although plastic surgeons and breast implant manufacturers admit that breast implants can cause ALCL, they claimed it was very rare.  For example, Allergan, a manufacturer of many different types of breast implants, claimed that “A woman is more likely to be struck by lightning than to get this condition.”[9]   However, 400 people are injured or killed by lightning every year,[10] which is why most people avoid situations where lightening can harm them.

In fact, the Australian version of the FDA now estimates that 1 in 1,000 women with breast implants will develop BIA-ALCL, [11] which is not nearly as rare as plastic surgeons and manufacturers have claimed.

Many women would not want to take the chance of developing cancer as a result of breast implants, and this is especially true for women who underwent mastectomies that were not medically necessary in an effort to reduce their chances of cancer returning.

It is also important to note that the link between breast implants and autoimmune diseases has been hotly debated for two decades, with many women reporting serious autoimmune symptoms that went away when their implants were removed.[11]  The scientific evidence regarding ALCL and implants once again raises questions about the possible impact of breast implants on autoimmune disease or symptoms such as joint pain, body pain, memory loss, and chronic fatigue.

For many years, women with breast implants were assured by implant companies, plastic surgeons, and the FDA that breast implants did not cause breast cancer or any other type of cancer. Evidence of a link to some types of cancer and to autoimmune diseases, including studies conducted by researchers at FDA and the National Cancer Institute, was dismissed. However, as everyone knows from data on lung cancer and smoking, it can take decades to determine if an exposure causes cancer or other serious diseases. Even a very strong carcinogen, such as tobacco, is very unlikely to cause lung cancer for at least 30 years.  For this reason, it is essential that physicians and researchers take a closer look at the link between breast implants and cancer of the immune system, as well as other immune disorders.

All articles are reviewed and approved by Dr. Diana Zuckerman and other senior staff.

References

1. Mazzucco, AE. Next Steps for Breast Implant-Associated Anaplastic Large-Cell Lymphoma. J Clin Oncol, 2014. Early release publication. June 16, 2014.
2. S. Food and Drug Administration. 26 January 2011. Web. June 25, 2012, <http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm241090.htm>
3. “Anaplastic Large Cell Lymphoma (ALCL) In Women with Breast Implants: Preliminary FDA Findings and Analyses.” January 2011. Center for Devices and Radiological Health. U.S. Food and Drug Administration. Web. June 25, 2012, <http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/BreastImplants/ucm239996.htm>
4. “FDA Questions and Answers about Anaplastic Large Cell Lymphoma (ALCL).” U.S. Food and Drug Administration. 26 January 2011. Web. June 25, 2012, <http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/BreastImplants/ucm241086.htm>
5. Kim B, Roth C, Young VL, Chung KC, van Busum K, et al. Anaplastic large cell lymphoma and breast implants: results from a structured expert consultation process. Plastic and Reconstructive Surgery. 2011 Sep;128(3):629-39.
6. Aladily TN, Medeiros JL, Amin, MB, Haideri N, et al. Anaplastic Large Cell Lymphoma Associated with Breast Implants: A Report of 13 Cases. Am J Surg Pathol. 2012 June 36(6).
7. end Miranda, et al. Breast Implant–Associated Anaplastic Large-Cell Lymphoma: Long-Term Follow-Up of 60 Patients. J Clin Oncol. 9 December 2013.
8. FDA Update on the Safety of Gel-Filled Breast Implants.” June 2011. Center for Devices and Radiological Health. U.S. Food and Drug Administration. Web. June 25, 2012, http://www.fda.gov/downloads/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/BreastImplants/UCM260090.pdf target=”_blank”>http://www.fda.gov/downloads/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/BreastImplants/UCM260090.pdf>
9. Edwards, Jim. “Breast Implant Maker Challenges FDA on Cancer Link.” CBS Money Watch. 27 January 2011. Web. 25 June http://www.cbsnews.com/8301-505123_162-42847224/breast-implant-maker-challenges-fda-on-cancer-link/ target=”_blank”>http://www.cbsnews.com/8301-505123_162-42847224/breast-implant-maker-challenges-fda-on-cancer-link/
10. Cooper, Mary Ann, MD. “Medical Aspects of Lightning.” National Weather Service. Web. 25 June 2012.http://www.lightningsafety.noaa.gov/medical.htm
11. Mazzucco, Anna, Ph.D and Zuckerman, Diana, Ph.D. “ALCL and Breast Implants: 2017 Update.” Breast Implant Information. Web. March 14, 2017. <http://www.breastimplantinfo.org/implantalcl/>