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Breast reduction surgery - does it help?

Systematic review
Results
Comment
Breast reduction and cancer
Results
Comment

Breast hypertrophy can be a real problem for some women. Reduction mammoplasty using various surgical techniques has become a more common treatment. Over the last 30 years about 32,000 such operations have been performed in Sweden, an average rate of about 25 per 100,000 women per year. That's about 12 a year in the average PCG, so a GP might see a case once every five years or so.

A new systematic review [1] pulls together the best available information. It informs about before and after symptoms, and is fascinating because this is one of those topics where randomised trials are rare as hen's teeth. So the question arises about dealing with different study architectures.

Systematic review


The authors [1] searched a variety of electronic databases for studies, using a number of different languages, and supplemented this with bibliographies and reviews. Studies that were case reports, abstracts, without outcomes of interest, with mixed procedures, in the setting of breast cancer, or with mixed genders, were not used. Those included had a minimum of 10 patients, were controlled trials, or case series, or historical or cross-sectional surveys, had a diagnosis of unilateral or bilateral breast hypertrophy or macromastia, used reduction mammoplasty and had clinical outcomes of interest.

The outcomes of interest were preoperative and postoperative reports of signs and symptoms and quality of life.

Results


Twenty-nine reports were included, with 4,200 women. Eighteen were observational studies, predominantly cross-sectional, and eleven were experimental studies, predominantly uncontrolled case series. The average age of women in the studies was about 36 years, with a wide range from 11 to 86 years. The average amount of breast tissue removed was about 1,500 grams from both breasts, with a range of 100 grams to 8,000 grams. Reduction was bilateral in over 90% of women. Observational and experimental studies had similar patient characteristics.

The frequency of reported symptoms before breast reduction was high (Table 1; Figure 1). Shoulder pain, and shoulder grooving caused by brassiere straps occurred in about 85% of women preoperatively, though back, neck and breast pain also occurred in over half of women before breast reduction, and intertrigo was also common. After the breast reduction the frequency of the symptoms reduced dramatically, and to about 10% on average (Figure 1; Table 1).

Table 1: Symptoms reported before and after breast reduction surgery

  Number of: % of women with the problem
  Studies Women Preoperative 95% CI Postoperative 95% CI
Shoulder pain 7 1829 85 (83-86) 6 (5-7)
Shoulder grooving 12 1838 84 (82-86) 8 (6-9)
Back pain 11 1153 73 (70-76) 13 (11-15)
Neck pain 11 1582 65 (63-68) 10 (8-11)
Breast pain 8 1364 50 (47-53) 13 (11-15)
Intertrigo 10 1513 50 (48-52) 4 (3-5)
Headache 7 1427 34 (31-36) 9 (7-10)
Pain/numbness in hand 4 934 19 (16-21) 7 (5-8)



Figure 1: Symptoms reported before and after breast reduction surgery



Comment


Breast hypertrophy is not a common condition. Most of us would rarely if ever think about it, and even less consider the problems for the women concerned. The occurrence of such a high frequency of pain in the shoulders, neck, back and breast is probably a surprise. The effect of breast reduction in reducing the frequency of these complaints is obvious, and for some symptoms, like neck and back pain, this may represent the rate in the general population.

The problem is that the quality of the studies is less than we come to expect from randomised double-blind trials. These are perhaps not appropriate in this situation, and we don't have them. What we do have is the best information available to us now, rather than the best information that might ever be available. Cries for more research are not much help when a woman walks in asking for help.

What we have is a number of studies, with information on over 4,000 women. They tell us of a big reduction in symptoms associated with breast reduction, and which makes sense from the mechanics of reduced strain on shoulders, neck and back.

We might also search for any other evidence that could help us decide whether breast reduction, on the whole, is a good thing. Studies documenting lower breast cancer risks after breast reduction [2,3] help the thinking.

Breast reduction and cancer


Both the studies were conducted in Sweden where a first class nationwide record linking system. Cancer, death, emigration and inpatient registers could be used to identify the 32,000 women who had breast reduction between 1965 and 1999, and to determine whether they subsequently developed breast cancer. One hundred and sixty one women did develop breast cancer, with 240,000 women-years, an average 7.5 year follow up.

Results


The first analysis [2] showed that there was a 28% reduction in the risk of breast cancer in women undergoing breast reduction.

The second study [3] retrieved hospital records of 137 of the women undergoing breast reduction and 422 of 483 matched controls in the breast reduction patients with similar risk factors for breast cancer, but who had not developed breast cancer. There was an impressive inverse correlation between amount of breast tissue removed and risk of breast cancer.

Compared with women who had less than 800 grams total tissue removed, those with more than 1600 grams removed had a 76% reduction in risk (Figure 2). Risk was significantly reduced for all amounts of tissue removed over 800 grams compared with less than 800 grams. This relationship was found to be the same for age, duration of follow up, weight, and parity.

Figure 2: Breast cancer risk after reduction surgery



Comment


That breast reduction reduces the risk of breast cancer comes from other studies as well, though the Swedish studies are notable for their completeness and strength. There is no grand unifying theory as yet, but having less breast tissue is clearly a candidate, despite there being no evidence that breast size is independently related to the risk of breast cancer.

It is always interesting when different bits of information come together to inform on a subject. Breast reduction is one of those topics of which many of us will be only dimly aware. Then along come a handful of papers full of evidence, and we feel we know much more than most.

References:

  1. EB Chadbourne et al. Clinical outcomes in reduction mammoplasty: a systematic review and meta-analysis of published studies. Mayo Clinic Proceedings 2001 76: 503-510.
  2. Boice JD et al. Breast cancer following breast reduction surgery in Sweden. Plastic and Reconstructive Surgery 2000 106: 755-762.
  3. LA Brinton et al. Breast cancer risk in relation to amount of tissue removed during breast reduction operations in Sweden. Cancer 2001 91: 478-483.
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