A systematic review and meta-analysis of risks and benefits with breast reduction in the public healthcare system: priorities for further research

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Abstract

Background

There is no consensus for when publicly funded breast reduction is indicated and recommendations in guidelines vary greatly, indicating a lack of evidence and unequal access. The primary aim of this review was to examine risks and benefits of breast reduction to treat breast hypertrophy. Secondary aims were to examine how the studies defined breast hypertrophy and indications for a breast reduction.

Methods

A systematic literature search was conducted in PubMed, MEDLINE All, Embase, the Cochrane Library, and PsycInfo. The included articles were critically appraised, and certainty of evidence was assessed using the GRADE approach. Meta-analyses were performed when possible.

Results

Fifteen articles were included; eight reporting findings from four randomised controlled trials, three non-randomised controlled studies, three case series, and one qualitative study . Most studies had serious study limitations and problems with directness. Few of the studies defined breast hypertrophy. The studies showed significantly improved health-related quality of life and sexuality-related outcomes in patients who had undergone breast reduction compared with controls, as well as reduced depressive symptoms, levels of anxiety and pain. Most effect sizes exceeded the reported minimal important difference for the scale. Certainty of evidence for the outcomes above is low (GRADE ⊕ ⊕). Although four studies reported significantly improved physical function, the effect is uncertain (very low certainty of evidence, GRADE ⊕). None of the included studies reported data regarding work ability or sick leave. Three case series reported a 30-day mortality of zero. Reported major complications after breast reduction ranged from 2.4 to 14% and minor complications from 2.4 to 69%.

Conclusion

There is a lack of high-quality studies evaluating the results of breast reduction. A breast reduction may have positive psychological and physical effects for women, but it is unclear which women benefit the most and which women should be offered a breast reduction in the public healthcare system. Several priorities for further research have been identified.

Pre-registration

The study is based on a Health Technology Assessment report, pre-registered and then published on the website of The Regional HTA Centre of Region Västra Götaland, Sweden.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-021-01336-7.

Related collections

Most cited references 63

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Is Open Access

Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement

David Moher, Larissa Shamseer, Mike Clarke … (2017)

Systematic reviews should build on a protocol that describes the rationale, hypothesis, and planned methods of the review; few reviews report whether a protocol exists. Detailed, well-described protocols can facilitate the understanding and appraisal of the review methods, as well as the detection of modifications to methods and selective reporting in completed reviews. We describe the development of a reporting guideline, the Preferred Reporting Items for Systematic reviews and Meta-Analyses for Protocols 2015 (PRISMA-P 2015). PRISMA-P consists of a 17-item checklist intended to facilitate the preparation and reporting of a robust protocol for the systematic review. Funders and those commissioning reviews might consider mandating the use of the checklist to facilitate the submission of relevant protocol information in funding applications. Similarly, peer reviewers and editors can use the guidance to gauge the completeness and transparency of a systematic review protocol submitted for publication in a journal or other medium.

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GRADE guidelines 6. Rating the quality of evidence--imprecision.

Gordon H Guyatt, Andrew D Oxman, Regina Kunz … (2011)

GRADE suggests that examination of 95% confidence intervals (CIs) provides the optimal primary approach to decisions regarding imprecision. For practice guidelines, rating down the quality of evidence (i.e., confidence in estimates of effect) is required if clinical action would differ if the upper versus the lower boundary of the CI represented the truth. An exception to this rule occurs when an effect is large, and consideration of CIs alone suggests a robust effect, but the total sample size is not large and the number of events is small. Under these circumstances, one should consider rating down for imprecision. To inform this decision, one can calculate the number of patients required for an adequately powered individual trial (termed the "optimal information size" [OIS]). For continuous variables, we suggest a similar process, initially considering the upper and lower limits of the CI, and subsequently calculating an OIS. Systematic reviews require a somewhat different approach. If the 95% CI excludes a relative risk (RR) of 1.0, and the total number of events or patients exceeds the OIS criterion, precision is adequate. If the 95% CI includes appreciable benefit or harm (we suggest an RR of under 0.75 or over 1.25 as a rough guide) rating down for imprecision may be appropriate even if OIS criteria are met. Copyright © 2011 Elsevier Inc. All rights reserved.

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Author and article information

Contributors

Emma Hansson:

ORCID: http://orcid.org/0000-0002-3218-0881

emma.hansson.2@gu.se

Journal

Journal ID (nlm-ta): BMC Surg

Journal ID (iso-abbrev): BMC Surg

Title: BMC Surgery

Publisher: BioMed Central (London )

ISSN (Electronic): 1471-2482

Publication date (Electronic): 11 September 2021

Publication date PMC-release: 11 September 2021

Publication date Collection: 2021

Volume: 21

Electronic Location Identifier: 343

Affiliations

[1 ]GRID grid.8761.8, ISNI 0000 0000 9919 9582, Department of Clinical Sciences, , Sahlgrenska Academy, University of Gothenburg, ; Gröna Stråket 8, SE-413 45 Gothenburg, Sweden

[2 ]GRID grid.1649.a, ISNI 000000009445082X, Department of Plastic and Reconstructive Surgery, , Region Västra Götaland, Sahlgrenska University Hospital, ; Gröna Stråket 8, SE-413 45, Gothenburg, Sweden

[3 ]Region Västra Götaland, Research and Development Primary Health Care, Kungsgatan 12, SE-411 19 Gothenburg, Sweden

[4 ]GRID grid.1649.a, ISNI 000000009445082X, Health Technology Assessment Centre, , Region Västra Götaland, Sahlgrenska University Hospital, ; Röda Stråket 8, 413 45 Gothenburg, Sweden

[5 ]GRID grid.8761.8, ISNI 0000 0000 9919 9582, Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, , The Sahlgrenska Academy, University of Gothenburg, ; Gothenburg, Sweden

[6 ]GRID grid.1649.a, ISNI 000000009445082X, Department of Surgery, , Region Västra Götaland, Sahlgrenska University Hospital, ; Blå Stråket, 413 46 Gothenburg, Sweden

[7 ]GRID grid.1649.a, ISNI 000000009445082X, Region Västra Götaland, Sahlgrenska University Hospital, Medical Library, ; Vita Stråket 12, SE-413 45 Gothenburg, Sweden

[8 ]GRID grid.8761.8, ISNI 0000 0000 9919 9582, School of Public Health and Community Medicine, Institute of Medicine, , University of Gothenburg, ; Gothenburg, Sweden

[9 ]GRID grid.8761.8, ISNI 0000 0000 9919 9582, Health Metrics, , The Sahlgrenska Academy, University of Gothenburg, ; Gothenburg, Sweden

Author information

Susanne Bernhardsson http://orcid.org/0000-0001-8212-7678

Mikael Svensson http://orcid.org/0000-0003-1113-7478

Fredrik Wärnberg http://orcid.org/0000-0002-6274-2435

Emma Hansson http://orcid.org/0000-0002-3218-0881

Article

Publisher ID: 1336

DOI: 10.1186/s12893-021-01336-7

PMC ID: 8436537

PubMed ID: 34511096

SO-VID: 3514030b-0ada-42b0-b39a-902772eedb7d

License:

Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

History

Date received : 17 February 2021

Date accepted : 28 August 2021

Funding

Funded by: University of Gothenburg

Open Access :

Open access funding provided by University of Gothenburg.

Custom metadata

ScienceOpen disciplines: Surgery

Keywords: breast reduction,reduction mammaplasty,breast hypertrophy,plastic surgery,evidence-based medicine,prioritizing

Data availability: