According to the American Society for Aesthetic Plastic Surgery (ASAPS), a recent study about suicide in women with breast implants, published in the British Medical Journal, is seriously flawed and, therefore, its conclusions are questionable. The study, entitled "Total and Cause Specific Mortality Among Swedish Women With Cosmetic Breast Implants: Prospective Study," is not a prospective study; it is a retrospective cohort study (1965-1993) that, significantly, does not examine patients' histories before breast surgery to determine the impact of variables known to be associated with increased risk of suicide, such as panic disorder, depression, and alcoholism.
It is noteworthy that the authors of the Swedish study do not conclude that their data show a causal association between implant surgery and suicide - in other words, there is no evidence that having breast implants in any way causes suicide. However, they suggest that an increased incidence of suicide among implant patients in this study and this patient population might reflect a higher incidence of severe psychological disturbance among women seeking cosmetic breast augmentation. No published study has demonstrated this to be so. The validity of this assertion requires much more extensive psychological evaluation than is included in this study.
To examine the issues raised by the Swedish study more scientifically, prospective studies are needed, and these must be designed to control for variables known to be associated with increased risk of suicide. Additionally, these studies would need to examine patients' histories before breast surgery and evaluate them psychologically following surgery. .
The American Society for Aesthetic Plastic Surgery (ASAPS) and its foundation, the Aesthetic Surgery Education and Research Foundation (ASERF), have sponsored research on psychological issues, patient satisfaction, and cosmetic surgery. These two organizations continue to educate their members with the goal of better serving the needs of patients.
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BMJ 2003;326:527-528 ( 8 March )
V C M Koot a Julius Centre for Health Sciences and Primary Care, University Medical Centre, Box 85500, 3508 GA Utrecht, Netherlands, b Department of Medical Epidemiology, Karolinska Institute, Box 281, S-171 77 Stockholm, Sweden
Correspondence to: V C M Kuck-Koot, Comprehensive Cancer Centre Middle Netherlands, PO Box 19079, 3501 DB Utrecht, Netherlands kuckkoot@ikmn.nl
The potential health hazards of breast implants have been heavily debated for the past decade, yet only one study has reported on long term mortality among women with such implants, and around one fifth of the participants were lost to follow up. 1 2 We assessed total and cause specific mortality among Swedish women who underwent augmentation mammoplasty between 1965 and 1993. As a desire for cosmetic surgery represents underlying psychopathology in some patients, we hypothesised that deaths due to suicide may be over-represented.3
Details about accrual of the cohort have been given elsewhere.4 We obtained records from the Swedish Inpatient Register of all 15-69 year old women who had had breast implants (n=7585) in 1965-93. We identified records with erroneous registration numbers or where emigration or death occurred before surgery through linkages with registers held by Statistics Sweden, using the unique national registration numbers. We excluded such records and records where surgery occurred at hospitals without surgical services (n=138). We also excluded women who had received an implant after surgery for breast cancer (n=3926), identified through the cancer register. The final study cohort comprised 3521 women, with a mean age of 31.6 (SD 8.6) years.
Follow up started on the day of first implantation surgery and stopped at date of emigration, death, or end of follow up (31 December 1994), whichever occurred first. The cohort members were followed for an average of 11.3 (range 0.3-29.9) years, corresponding to 39 735 person years at risk. We compared the observed number of deaths with the expected number of deaths, the ratio of these two numbers giving the standardised mortality ratio. We obtained the expected number of deaths by multiplying the observed number of person years at risk in the cohort, divided into 5 year age strata and 1 calendar year strata, by the stratum specific mortality rates, derived from official Swedish death statistics. The standardised mortality ratio can therefore be viewed as a measure of relative risk, with the Swedish female population matched for age and calendar year serving as reference. We calculated 95% confidence intervals, assuming that the number of observed events followed a Poisson distribution. We coded underlying causes of death according to the international classification of diseases (7th, 8th, and 9th revisions) into suicide, unintentional injury, cardiovascular diseases, malignancies, and other causes.
Although 58.7 deaths were expected, 85 women died (standardised mortality ratio 1.5, 1.2 to 1.8; table). Fifteen women committed suicide, compared with 5.2 expected deaths (2.9, 1.6 to 4.8). Excess deaths were also due to malignant disease (1.4, 1.0 to 1.9), mainly lung cancer. The number of deaths for all other causes was close to expected.
Standardised mortality ratios for total and cause specific mortality in 3521 Swedish women with cosmetic breast implants
Women who undergo cosmetic surgery for breast augmentation are more likely to commit suicide than women from the general population. The 50% excess mortality found by us in our prospective study of 3000 Swedish women contrasts with the decreased mortality reported from the United States.2 This may reflect different reasons for self selection for plastic surgery or may be an effect of losses to follow up in the American study. Both the American study and our study did, however, show an increased risk for suicide in women opting for breast augmentation. Our excess mortality was explained by the excess of suicides and deaths from malignant disease. Deaths due to malignancy were mainly linked to smoking, previously shown as common in our cohort.5 Given the well documented link between psychiatric disorders and a desire for cosmetic surgery, the increased risk for death from suicide may reflect a greater prevalence of psychopathology rather than a causal association between implant surgery and suicide.3 Surgeons evaluating candidates for breast implant surgery need to be vigilant for subtle signs of psychiatric problems.
Contributors: VCMK, the principal investigator, discussed the core ideas, performed the record linkages, outlined and performed analyses, and wrote most of the paper. PHMP discussed the core ideas and participated in data interpretation and writing of the paper. FG participated in discussions about the core ideas, made suggestions about analyses, and helped VCMK with the practical analysis. DEG discussed the core ideas, the design of the study, the interpretation of the data, and writing of the paper. ON initiated the research, discussed the core ideas, formulated the primary study hypothesis, made suggestions about analyses and interpretation of the data, and supervised the writing. DEG and ON will act as guarantors for the paper.
Funding: This work was supported by a contract from the International Epidemiology Institute, Rockville, MA. VCMK was financially supported by the Netherlands Organization for Scientific Research.
Competing interests: None declared.
Angell M.
Evaluating the health risks of breast implants: the interplay of medical science, the law, and public opinion. N Engl J Med 1996; 334: 1513-1518
Brinton LA, Lubin JH, Burich MC, Colton T, Hoover RN.
Mortality among augmentation mammoplasty patients. Epidemiology 2001; 12: 321-326[CrossRef][ISI][Medline].
Hasan JS.
Psychological issues in cosmetic surgery: a functional overview. Ann Plast Surg 2000; 44: 89-96[ISI][Medline].
Nyren O, Yin L, Josefsson S, McLaughlin JK, Blot WJ, Engqvist M, et al.
Risk of connective tissue disease and related disorders among women with breast implants: a nation-wide retrospective cohort study in Sweden. BMJ 1998; 316: 417-422
Fryzek JP, Weiderpass E, Signorello LB, Hakelius L, Lipworth L, Blot WJ, et al.
Characteristics of women with cosmetic breast augmentation surgery compared with breast reduction surgery patients and women in the general population of Sweden. Ann Plast Surg 2000; 45: 349-356[ISI][Medline].
(Accepted 17 January 2003)
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Total and cause specific mortality among Swedish women with cosmetic breast implants: prospective study
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Comment Comment
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References References
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