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:
- 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.
- Boice JD et al. Breast cancer following breast reduction surgery in Sweden.
Plastic and Reconstructive Surgery 2000 106: 755-762.
- 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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