Viewpoints Oncologic Imaging in Patients Undergoing Breast Reduction Ajul Shah, MD Alexander Sun, BS Brandon Sumpio, BS Victor Zhu, BS Section of Plastic and Reconstructive Surgery Department of Surgery Yale University School of Medicine New Haven, Conn. Liane Philpotts, MD Department of Diagnostic Radiology Yale University School of Medicine New Haven, Conn. Alexander Au, MD Mark Melendez, MD, MBA Section of Plastic and Reconstructive Surgery Yale University School of Medicine New Haven, Conn.
Sir:
H
ealthcare and cancer organizations in the United States have not published specific recommendations for mammography screening in patients undergoing breast reduction.1 Because of the considerable variability in the proposed protocols for oncologic imaging in patients undergoing breast reduction, the authors of this article seek to determine the most commonly followed practices throughout the United States and the world.
METHODS
A web-based survey consisting of 9 questions was sent to surgeons using the list server of the American Society of Plastic Surgeons (Table 1). Their responses were recorded, and statistical correlations were investigated.
RESULTS
The survey was sent to 7,836 members, whereas it returned “undeliverable” for 1,201 members. Six hundred seventy-four responses were obtained (response rate, 10.1%). Ninety-three percent state that they routinely perform a breast examination preoperatively. Sixty-two percent state that they routinely request preoperative radiography screening, and of those, 93% request mammography. Of note, 46% do not follow a postoperative protocol for mammography screening (Supplemental Digital Content 1, which displays survey results in graph format, http://links. lww.com/PRSGO/A228). Copyright © 2016 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons. All rights reserved. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially. Plast Reconstr Surg Glob Open 2016;4:e756; doi:10.1097/ GOX.0000000000000812; Published online 20 June 2016.
Table 1. Survey Questions 1. Number of years in practice? 2. Are you employed in university or private practice? 3. Approximately, how many breast reductions do you perform per year? 4. Are you aware of current breast screening guidelines? If yes, what guidelines? 5. Do you routinely perform a breast examination before performing a breast reduction? 6. Do you routinely request a radiography screening? If yes, what do you request? 7. Would patient’s insurance coverage change your practice regarding screening? 8. Is breast tissue routinely sent for pathology at the time of reduction? 9. Do you follow a postoperative protocol for mammography screening? If yes, what protocol?
Providers who perform more breast reductions are more likely to be aware of current screening guidelines (P = 0.0064). The shorter time a provider has been in practice, the more aware they are of current screening guidelines (P = 0.01), and the longer a provider has been in practice, the more likely they are to follow a postoperative protocol for screening (P = 0.0252). Also, if the provider works in a private practice setting, he/ she is more likely to routinely request preoperative radiography screening than if in an academic setting (P = 0.0341).
DISCUSSION
Breast reduction can leave changes in the breast that may have oncologic significance although there is conflicting evidence on this matter. Proponents of increased perioperative imaging would argue that the changes within the breast could simulate the mammographic findings of carcinoma.2,3 Those who would argue against increased imaging cite research performed by radiologists that has characterized mammographic findings after reduction mammoplasty and found that postoperative changes are predictable and distinguishable from neoplasms.4 Our study confirms the highly variable screening protocols demonstrated by providers performing breast reduction. Of those surveyed, 45.7% of responders do not follow a postoperative protocol for mammography screening. These providers likely hold to the belief that postoperative changes seen on radiography can be readily differentiated from carcinoma, supported by some of the previously mentioned literature. Nearly 5% of respondents do not send tissue to pathology for analysis. There are numerous reports and studies that demonstrate the possibility of finding breast cancer in specimens sent during breast reduction.5 By Supplemental digital content is available for this article. Clickable URL citations appear in the text.
www.PRSGlobalOpen.com
1
PRS Global Open • 2016 not sending tissue for pathologic analysis, the provider may be putting the patient at risk for undetected carcinoma. Although this risk is low, the potential cost of missing a lesion is high.
CONCLUSIONS
Our study evaluates the oncologic screening practices in plastic surgeons performing breast reduction. This study demonstrates the considerable variability in screening protocols and demonstrates the need for standardization of these practice parameters Ajul Shah, MD Plastic and Reconstructive Surgery Yale University School of Medicine 3rd Floor, Boardman Building 330 Cedar Street New Haven, CT 06520 E-mail: [email protected]
2
Disclosure
The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors. REFERENCES 1. Kerrigan CL, Slezak SS. Evidence-based medicine: reduction mammaplasty. Plast Reconstr Surg. 2013;132:1670–1683. 2. Brown FE, Sargent SK, Cohen SR, et al. Mammographic changes following reduction mammaplasty. Plast Reconstr Surg. 1987;80:691–698. 3. Miller CL, Feig SA, Fox JW 4th. Mammographic changes after reduction mammoplasty. AJR Am J Roentgenol. 1987;149:35–38. 4. Danikas D, Theodorou SJ, Kokkalis G, et al. Mammographic findings following reduction mammoplasty. Aesthetic Plast Surg. 2001;25:283–285. 5. Jansen DA, Murphy M, Kind GM, et al. Breast cancer in reduction mammoplasty: case reports and a survey of plastic surgeons. Plast Reconstr Surg. 1998;101:361–364.
Sir:
H
ealthcare and cancer organizations in the United States have not published specific recommendations for mammography screening in patients undergoing breast reduction.1 Because of the considerable variability in the proposed protocols for oncologic imaging in patients undergoing breast reduction, the authors of this article seek to determine the most commonly followed practices throughout the United States and the world.
METHODS
A web-based survey consisting of 9 questions was sent to surgeons using the list server of the American Society of Plastic Surgeons (Table 1). Their responses were recorded, and statistical correlations were investigated.
RESULTS
The survey was sent to 7,836 members, whereas it returned “undeliverable” for 1,201 members. Six hundred seventy-four responses were obtained (response rate, 10.1%). Ninety-three percent state that they routinely perform a breast examination preoperatively. Sixty-two percent state that they routinely request preoperative radiography screening, and of those, 93% request mammography. Of note, 46% do not follow a postoperative protocol for mammography screening (Supplemental Digital Content 1, which displays survey results in graph format, http://links. lww.com/PRSGO/A228). Copyright © 2016 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons. All rights reserved. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially. Plast Reconstr Surg Glob Open 2016;4:e756; doi:10.1097/ GOX.0000000000000812; Published online 20 June 2016.
Table 1. Survey Questions 1. Number of years in practice? 2. Are you employed in university or private practice? 3. Approximately, how many breast reductions do you perform per year? 4. Are you aware of current breast screening guidelines? If yes, what guidelines? 5. Do you routinely perform a breast examination before performing a breast reduction? 6. Do you routinely request a radiography screening? If yes, what do you request? 7. Would patient’s insurance coverage change your practice regarding screening? 8. Is breast tissue routinely sent for pathology at the time of reduction? 9. Do you follow a postoperative protocol for mammography screening? If yes, what protocol?
Providers who perform more breast reductions are more likely to be aware of current screening guidelines (P = 0.0064). The shorter time a provider has been in practice, the more aware they are of current screening guidelines (P = 0.01), and the longer a provider has been in practice, the more likely they are to follow a postoperative protocol for screening (P = 0.0252). Also, if the provider works in a private practice setting, he/ she is more likely to routinely request preoperative radiography screening than if in an academic setting (P = 0.0341).
DISCUSSION
Breast reduction can leave changes in the breast that may have oncologic significance although there is conflicting evidence on this matter. Proponents of increased perioperative imaging would argue that the changes within the breast could simulate the mammographic findings of carcinoma.2,3 Those who would argue against increased imaging cite research performed by radiologists that has characterized mammographic findings after reduction mammoplasty and found that postoperative changes are predictable and distinguishable from neoplasms.4 Our study confirms the highly variable screening protocols demonstrated by providers performing breast reduction. Of those surveyed, 45.7% of responders do not follow a postoperative protocol for mammography screening. These providers likely hold to the belief that postoperative changes seen on radiography can be readily differentiated from carcinoma, supported by some of the previously mentioned literature. Nearly 5% of respondents do not send tissue to pathology for analysis. There are numerous reports and studies that demonstrate the possibility of finding breast cancer in specimens sent during breast reduction.5 By Supplemental digital content is available for this article. Clickable URL citations appear in the text.
www.PRSGlobalOpen.com
1
PRS Global Open • 2016 not sending tissue for pathologic analysis, the provider may be putting the patient at risk for undetected carcinoma. Although this risk is low, the potential cost of missing a lesion is high.
CONCLUSIONS
Our study evaluates the oncologic screening practices in plastic surgeons performing breast reduction. This study demonstrates the considerable variability in screening protocols and demonstrates the need for standardization of these practice parameters Ajul Shah, MD Plastic and Reconstructive Surgery Yale University School of Medicine 3rd Floor, Boardman Building 330 Cedar Street New Haven, CT 06520 E-mail: [email protected]
2
Disclosure
The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors. REFERENCES 1. Kerrigan CL, Slezak SS. Evidence-based medicine: reduction mammaplasty. Plast Reconstr Surg. 2013;132:1670–1683. 2. Brown FE, Sargent SK, Cohen SR, et al. Mammographic changes following reduction mammaplasty. Plast Reconstr Surg. 1987;80:691–698. 3. Miller CL, Feig SA, Fox JW 4th. Mammographic changes after reduction mammoplasty. AJR Am J Roentgenol. 1987;149:35–38. 4. Danikas D, Theodorou SJ, Kokkalis G, et al. Mammographic findings following reduction mammoplasty. Aesthetic Plast Surg. 2001;25:283–285. 5. Jansen DA, Murphy M, Kind GM, et al. Breast cancer in reduction mammoplasty: case reports and a survey of plastic surgeons. Plast Reconstr Surg. 1998;101:361–364.
