We read with interest the article entitled “Incidence of Precancerous Lesions in Breast Reduction Tissue: A Pathologic Review of 562 Consecutive Patients” in the October of 2009 issue of Plastic and Reconstructive Surgery.1 In their article, the authors present the first study to assess a patient's individual breast cancer risk on the basis of breast reduction specimen findings by applying the College of American Pathologists consensus statement. The group included 562 consecutive patients seeking breast reduction at a single institution; the mean age of the study group was 43 years. This included patients with a history of (or current) breast cancer seeking balancing reductions with concomitant breast reconstruction. They state that 11.2 percent of the group had a personal history of breast cancer before reduction, which is not typical of the macromastia population. They conclude from their study that no invasive carcinoma was found in the reduction specimens; however, over 50 percent had benign or precancerous breast lesions. They found, as expected, that patients with a personal history of breast cancer were more likely to have ductal or lobular carcinoma findings in reduction specimens, and younger patients were more likely to have normal findings.
Our review of the article yielded the following few comments. First, this is not a homogeneous study population. To extrapolate pathologic findings in this group to the typical population seeking reduction mammaplasty would not be entirely accurate. Second, it is unclear what perioperative guidance the authors recommend for patients found to have an increased risk of breast cancer based on this study. Third, in this era of cost containment and population-based healthcare reform, the cost of routine pathologic sampling must be considered.
In 2007, at the 24th Annual Meeting of the Northeastern Society of Plastic Surgeons, our group presented a study on the cost of sending all reduction specimens for pathologic evaluation. As the current study documents, we found no cases of occult carcinoma in our series. Benign pathologic findings were common, being present in 86.4 percent. This routine pathologic examination is costly. The internal institutional cost averaged $65 per breast reduction specimen. The external costs averaged $118 per specimen as measured by Medicare data. The contribution margin per specimen to the Department of Pathology was approximately $50. The American Society of Plastic Surgeons reports that 212,358 breast reductions were performed in the United States in 2007.2 Therefore, the total cost to the healthcare system for microscopic examination of breast reduction specimens approaches $25,058,244 annually. Given the estimated incidence of occult carcinoma referenced by the author, it costs $236,000 to diagnose one breast cancer.
We have subsequently looked more closely at the adolescent breast reduction population (younger than 18 years) in our institution over the past 10 years. Pathologic examination yielded entirely normal or mildly fibrotic histologic findings in 80 percent of specimens. Benign pathologic findings were observed in the remaining 20 percent, including fibroadenoma, fibrocystic change, ductal hyperplasia (without atypia), and other benign pathologic findings. No cancers or premalignant lesions were identified. Using the same cost data as above, and realizing the incidence of adolescent breast cancer in 0.08 cases per 100,000, the cost of one cancer diagnosis is $147 million to the healthcare system. These results are in their final stage of write-up and will be accompanied by indications, techniques, and outcomes in a future submission for publication.
The incidence of occult carcinoma identified in the reduction mammaplasty samples of the macromastia population is low. Serendipitous identification of such cancer is expensive. The cost effectiveness of routine pathologic examination following reduction mammaplasty is questionable and should be reconsidered. This is especially true in the younger patient population and the patient without prior personal history of breast cancer.
Peter F. Koltz, M.D.
John A. Girotto, M.D.
Division of Plastic and Reconstructive Surgery
University of Rochester Medical Center
1.Clark CJ, Whang S, Paige KT. Incidence of precancerous lesions in breast reduction tissue: A pathologic review of 562 consecutive patients. Plast Reconstr Surg.
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