Breast Cancer Diagnosis in the Augmented Patient

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Abstract
To the Editor.—Silverstein et al1 report that in their clinic, breast cancers diagnosed in women with augmentation mammoplasties were more advanced than in nonaugmented patients. They imply that the delay in diagnosis is due to the implant obscuring and compressing the breast, thus reducing the effectiveness of mammography. In light of published evidence that they did not discuss, and in light of potentially serious design flaws in their study, their data do not support their conclusions and should be considered with great skepticism. Specialty clinics in large urban areas are exceptionally vulnerable to referral bias that can produce overestimations or underestimations of associations. No referral information is provided, and the fact that none of the augmented patients presented until their masses had been palpable for up to two years (mean, 123 days) suggests that the behavior of these patients may be much different from that of the nonaugmented

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