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Sears ED, Lu Y, Swiatek PR, Chung T, Kerr EA, Chung KC. Use of Preoperative Mammography During Evaluation for Nononcologic Breast Reduction Surgery. JAMA Surg. 2019;154(4):356–358. doi:10.1001/jamasurg.2018.4875
More than 500 000 elective breast operations are performed annually in the United States.1 Through the Choosing Wisely Campaign, the American Society of Plastic Surgeons recommend that women undergoing elective breast surgery should not receive routine preoperative mammography beyond what existing guidelines recommend for all women, considering risk factors and age, unless a specific concern exists.2 In an analysis of the American Board of Plastic Surgery Maintenance of Certification data, 23% of women younger than 40 years underwent mammography before reduction mammoplasty.3 Given that reduction mammoplasty is one of the most common elective breast operations,4 we aimed to assess use of preoperative mammography for patients undergoing evaluation for macromastia and to measure rates of subsequent diagnostic tests and breast disease in women receiving mammography, in particular among women younger than 40 years.
This study received exempt status from the institutional review board of the University of Michigan, Ann Arbor, which waived the need for informed consent. The study cohort included adult women with a primary diagnosis of macromastia in the 2009-2015 Truven MarketScan databases,5 identified by diagnosis codes from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). We excluded patients who were not included in the data set at least 12 months before and after the macromastia diagnosis. Women were also excluded if they had ICD-9-CM diagnosis codes for personal or family history of breast cancer, genetic predisposition to breast cancer, or prior benign breast disease. We used Current Procedural Terminology codes to identify a subset of women who received screening or diagnostic mammograms 12 months before or after the first macromastia encounter and before surgery, if performed. We noted subsequent tests (magnetic resonance imaging, ultrasonography, and biopsy) performed and new diagnoses of malignant or benign breast disease within 3 months of mammography. For comparison, a cohort of women of similar age who did not undergo evaluation for macromastia was assessed from the 2013 data set. We compared frequency of use of age-specific mammography between the macromastia and nonmacromastia cohorts with the χ2 test, with 1-sided P < .05 indicating significance. Data were analyzed from March 2, 2017, through March 25, 2018.
The final cohort consisted of 52 486 women undergoing evaluation for macromastia from January 1, 2010, through September 30, 2014 (mean [SD] age, 43  years). Mammograms were used in 31 284 patients (59.6%). Within 12 months of evaluation, 44.6% of patients received breast reduction surgery (44.1% in the mammography group vs 45.3% in the nonmammography group). Among women with macromastia aged 30 to 39 years, 3657 (30.1%) received mammograms, compared with 74 593 (5.7%) of the general population cohort (P < .001) (Table 1). Patients 29 years and younger with macromastia also had a higher rate of mammography use (383 [4.3%]) compared with the general population group (2899 [0.2%]) (P < .001).
Of the 2322 patients in the macromastia group 39 years and younger who received screening mammography, 324 (14.0%) received at least 1 subsequent test or procedure (magnetic resonance imaging, ultrasonography, or biopsy) within the 3 months after mammography, whereas 12 (0.5%) were diagnosed with malignant breast disease after mammography (Table 2). A subsequent biopsy was performed in 90 patients (3.9%) 39 years or younger with macromastia within 3 months of screening mammography.
Our study showed that altering screening mammography practices for patients younger than 40 years in the setting of evaluation for macromastia has a risk for subsequent tests and invasive procedures. Given the inconvenience, costs, and patient anxiety associated with subsequent tests and procedures and the potential for further complications, policy and guidelines to promote awareness and shared decision making for patients are needed if screening recommendations are altered for young patients who present for elective breast surgery. In some instances, these tests may be mandated before the surgical consultation, regardless of risk factors or age. A limitation of this study includes the lack of clinical details to determine appropriate vs inappropriate testing and the inability to identify false-positive findings after testing. Although cancer detection rates in this study met acceptable American College of Radiology benchmarks,6 health care professionals must be informed and advise patients of the effects of mammography use before elective breast surgery among patients of average risk who would not otherwise receive screening, because screening has an associated risk for subsequent tests and invasive procedures.
Accepted for Publication: September 23, 2018.
Corresponding Author: Erika D. Sears, MD, MS, Section of Plastic Surgery, Department of Surgery, Michigan Medicine, Room 2130 Taubman Center, 1500 E Medical Center Dr, Ann Arbor, MI 48109 (email@example.com).
Published Online: December 26, 2018. doi:10.1001/jamasurg.2018.4875
Author Contributions: Dr Sears had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Sears, Lu, Swiatek, K. Chung.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Sears, Lu, Swiatek, K. Chung.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Sears, Lu, Swiatek, T. Chung, K. Chung.
Obtained funding: Sears, K. Chung.
Administrative, technical, or material support: Sears, Lu, K. Chung.
Supervision: Sears, K. Chung.
Conflict of Interest Disclosures: None reported.
Funding/Support: The study was supported in part by a grant from the Plastic Surgery Foundation (Drs Sears and K. Chung); Career Development Award IK2 HX002592 from the US Department of Veterans Affairs Health Services Research and Development Service (Dr Sears); grants CORPG3G0111 and CORPG3G0161 from Chang Gun Memorial Hospital project (Ms Chung); award 2 K24-AR053120-06 from the National Institute of Arthritis and Musculoskeletal and Skin Diseases of the National Institutes of Health (Dr Chung); and a Midcareer Investigator Award in Patient-Oriented Research.
Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs, the University of Michigan, or the National Institutes of Health.
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