Time for equal access to breast reduction surgery in Australia

Women with symptomatic macromastia need relief from a condition that can seriously impair their quality of life

In this issue of the MJA, Crittenden and colleagues report their cost–utility analysis of breast reduction surgery for women with symptomatic breast hypertrophy in Australia.1 Their key finding is that breast reduction surgery is cost‐effective, the cost per quality‐adjusted life‐year (QALY) being considerably lower than the recommended willingness to pay thresholds in the Australian health care system. The authors prospectively assessed health‐related quality of life (SF‐6D utility scores) for 209 women with symptomatic breast hypertrophy before and 12 months after breast reduction surgery. The SF‐6D, a six‐dimensional single health utility score, is derived from the Short Form‐36 (SF‐36), one of the most widely used instruments for assessing health‐related quality of life (range: 0 for death to 1 for perfect health). Their scores were compared with those for 124 women with similar symptoms who had not yet had reduction surgery. The mean SF‐6D scores were similar at baseline, and improved significantly for the women who had undergone surgery (0.313; standard deviation [SD], 0.263 to 0.626; SD, 0.277) but declined slightly (0.296; SD, 0.267 to 0.270; SD, 0.257) for those who had not. The effectiveness of the procedure was measured as the mean differential QALY gain (1.519; 95% confidence interval, 1.362–1.675), obtained at an incremental cost‐effectiveness ratio (ICER) of $7808 per QALY gained.

Breast hypertrophy (macromastia) can lead to both physical and psychological problems in women. Common symptoms are chronic neck and shoulder pain, headaches, skin irritation, inability to participate in vigorous physical activities, reduced self‐confidence, and, potentially, social isolation and depression. Conservative management, such as physiotherapy and weight loss, relieves symptoms only marginally, whereas breast reduction surgery can markedly mitigate these problems.2 In a previous report on clinical outcome data from the same prospective cohort study, Crittenden and colleagues used the SF‐36 health‐related quality of life instrument.3 At baseline, both physical and mental scores were significantly lower in all domains for women with breast hypertrophy than for the general population, but had improved to normal levels by three months after surgery. Improvement was maintained at six and twelve months, and was considerably greater than the pre‐defined minimally important difference.3 A subset of patients in this study completed the BREAST‐Q Reduction module,4 a validated, breast‐specific, patient‐reported outcome measure (range, 0–100). The mean score for “satisfaction with breasts” was strikingly low before surgery (21.9; SD, 10.9), but higher than for the general population after surgery (73.3; SD, 17.3). Scores for psychosocial, physical, and sexual wellbeing were also markedly lower before surgery but similar to those of the general population after surgery. Interestingly, improvement was evident in all patient categories, regardless of body mass index, age, or complications.4 Prospective randomised studies in Finland, Brazil, and the United Kingdom have yielded similar results.5,6 However, many studies have been limited by small sample sizes or retrospective designs.7

The risk of complications after breast reduction surgery is relatively high, but most complications are minor, typically involving wound healing, and can be managed outside the hospital; only 5% require surgical intervention.8 Although breast shape may change over time, the positive effects on health‐related quality of life persist for longer than the ten years extrapolated by Crittenden and colleagues.6,9

Breast reduction is available to patients in Australia in the private health care system, with the procedure listed on the Medicare Benefits Schedule (MBS) for “patients with macromastia and experiencing pain in the neck or shoulder region”.10 However, access for patients in the public health system is very limited and differs between jurisdictions; breast reduction is classified as cosmetic surgery in some states, and is generally permitted only in exceptional cases. The study by Crittenden and colleagues, the first Australian cost–utility analysis of breast reduction surgery, enables comparison with other interventions for improving health‐related quality of life currently accessible to public health system patients. Breast reduction compares very favourably with other widely accepted interventions, such as hip or knee replacement, cataract surgery, and bariatric surgery.3

One problem, however, is that evidence‐based criteria for determining who might derive most benefit from this type of surgery are not available. Developing a health‐related quality of life selection tool would be useful, similar to the currently used NOSE scale included in the MBS indications for rhinoplasty.11

Women with symptomatic macromastia are not looking for cosmetic procedures, but seeking relief from a condition that can seriously impair their quality of life. Ambivalent societal attitudes to breast procedures should not interfere with best practice management.