Five Questions With: Dr. Ethan Balk

Dr. Ethan Balk, assistant professor of health services, policy and practice at Brown University, recently led a study looking at the health outcomes associated with silicone gel breast implants.
Dr. Ethan Balk, assistant professor of health services, policy and practice at Brown University, recently led a study looking at the health outcomes associated with silicone gel breast implants.

Dr. Ethan Balk is assistant professor of health services, policy and practice at Brown University. After several years of practicing as a primary care physician, he has pursued a career in systematic review, meta-analysis and clinical development. He previously served as associate director of the Tufts Evidence-based Practice Center and director of the Tufts Center for Clinical Evidence Synthesis and has more than 125 publications on systematic reviews of a wide range of medical, surgical, health and nutrition topics. He recently led a study looking at the health outcomes associated with silicone gel breast implants.

PBN: What are the main take-away messages from this study?
BALK:
There are two main conclusions from our study, one for women and their surgeons, the other for the research community. There may be some indications that silicone gel implants may be associated with increased risk of some connective tissue diseases and lung cancer, and decreased risk of breast and endometrial cancer. But the evidence regarding this question is poor and inconclusive overall. Better analyses and studies are needed. Both new studies and, if possible, re-analyses of old studies are needed to get better answers regarding the long-term health outcomes in women with silicone gel breast implants. It is important to adjust analyses for a wide range of inherent differences between women who choose to have implants and women without implants.

PBN: Why is it challenging to disentangle different factors when it comes to silicone breast implants?
BALK:
Women who choose to have breast implants, either for augmentation or after mastectomy, are different in many ways from women without implants. As examples, women who have implants for augmentation are more likely to smoke and drink alcohol, be thin, use oral contraceptives, but have more children. Also, in one study, women who wanted implants experienced greater distress and more frequent teasing about their appearance and more frequent use of psychotherapy. Some of these factors may be relatively easy to adjust for, such as tobacco history, but others cannot easily be controlled for, such as the psychosocial differences.

PBN: Were you close at any point during this study to coming down on one side or the other, or did the data come in evenly from beginning to end?
BALK:
The systematic review process evaluates all available, relevant studies as a whole. The goals are to minimize bias that may occur by focusing on individual studies and to form a conclusion based on the totality of the evidence. Although we found 32 studies of long-term health outcomes of silicone gel breast implants, very few of them were judged to have adequate analyses.

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PBN: How prevalent is the use of silicone breast implants in the United States today versus 25 years ago?
BALK:
In 2012, more than 300,000 women underwent breast augmentation and about 92,000 women underwent breast reconstruction with silicone implants in the United States, accounting for a 16 percent increase since 2000.

PBN: Is there a lot of variation in health outcomes when it comes to using products made by the different manufacturers of the implants? If so, what makes the best implants especially safe?
BALK:
In conducting the review, we aimed to compare outcomes across different types of silicone gel implants, including those made by different manufacturers. Almost all studies did not report any data about the specific implants that women had implanted. In fact, most studies analyzed silicone gel implants with saline implants. Worth noting is the fact that saline implants have silicone shells. Therefore, we were unable to make any conclusions about different specific implants. Overall, the studies fail to conclusively show whether silicone gel implants are associated with long-term harms.

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