Should breast tissue be screened for cancer after mammoplasty?

Young women undergoing cosmetic breast reduction surgery are being screened for cancer without their informed consent, according to a paper published on bmj.com.

Breast reduction surgery (mammoplasty) is one of the most common procedures performed by plastic surgeons all around the world. For decades it has been common practice to test the removed tissue for cancer.

The incidence of cancer found after surgery is small and often clinically insignificant. But, if found, it can lead to further surgery of unproven benefit. So should the current practice of routinely testing tissue after surgery be abandoned, or should doctors discuss this issue in advance with the patient and ensure that they are aware of the possible consequences?

A team of breast surgeons based at the Royal Free Hampstead NHS Trust and Royal Free and University College Medical School in London describe finding cancer after a routine cosmetic operation on a 37 year old woman. The discovery led to a succession of further operations, but the team question the ethics of acting on test results when there is no evidence for benefit.

They also point out that it is often not possible to identify exactly where in the breast the tissue came from because tissue specimens are not orientated during surgery.

In an accompanying commentary, Tom Treasure, a Professor of Cardiothoracic Surgery at University College London suggests that the question of what is the best management of a patient with these findings in the future remains unanswered. "Not putting the tissue under the microscope may seem unacceptable," he writes, "but so is continuing surgical practices that may result in harm, without having evidence of benefit."

In a second commentary, ethicist Jeremy Sugarman suggests that even though the likelihood of the specimens being malignant is small, discussing this issue in advance should help to prepare patients to receive the news and to face the complex decisions that follow. He believes that this matter warrants careful, expert review. In the meantime, he suggests that obtaining informed consent for screening and orientating these specimens should help to mitigate some of the difficult ethical issues that are encountered in practice.

Like any potential patient, I welcome any procedures made to safeguard my health and would appreciate being informed of every aspect (and associated risk) of an operation. I would not appreciate being left in the dark, writes Tessa Boase, in a final commentary. She believes that the current practice of screening of breast tissue after reduction mammoplasty should be maintained and perhaps refined, but the patient should, from start to finish, be kept in the loop. "Who else, after all, is this screening supposed to benefit?" she says.

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