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Abstract

Sir: We appreciate the insightful comments provided by Drs. Koltz and Girotto regarding our article on the incidence of precancerous breast lesions in breast reduction tissue and look forward to their contribution to this topic in the near future. In response to specific comments, we recognized that breast cancer patients may be overrepresented in our patient group, but we felt it to be important to include this subgroup in our analysis because a history of breast cancer would likely increase one's incidence of contralateral breast disease. Second, this study emerged as a result of patients questioning our surgeons on their risk of finding abnormal breast tissue at the time of reduction. As a result of this study, we have made concerted efforts to counsel our patients on the likelihood of identifying atypical ductal hyperplasia, atypical lobular hyperplasia, lobular carcinoma in situ, or ductal carcinoma in situ and the subsequent follow-up with an oncologist if indicated. Our report was not a longitudinal study designed to define a patient's risk of breast cancer as a result of incidental precancerous lesions identified at the time of reduction mammaplasty. The clinical relevance of precancerous breast lesions discovered in breast reduction specimens remains to be defined. However, in a Danish population-based study, Baasch et al. reported that reduction mammaplasty can reduce one's risk of breast cancer.1 In light of recommendations by the U.S. Preventive Services Task Force that only women older than 50 years should undergo biennial screening mammography, patients found to have incidental precancerous lesions that are younger than 50 years may constitute a subgroup of the population that could benefit from earlier screening.2 In addition to postoperative screening mammography, this subgroup may benefit from treatment with a selective estrogen receptor modulator (tamoxifen or raloxifene) as demonstrated in the National Surgical Adjuvant Breast and Bowel Project Study of Tamoxifen and Raloxifene trial.3 Lastly, the cost of processing pathology specimens is a serious concern. We reported that 1.1 percent of patients will have incidental ductal carcinoma in situ in their reduction specimen, and recently, Ambaye et al. reported that with extensive tissue sampling, 2.5 percent of patients will have incidental ductal carcinoma in situ or invasive adenocarcinoma of the breast.4,5 Thus, based on crude calculations, routine pathologic sampling of reduction mammaplasty specimens costs $2250 to $10,719 per diagnosis of ductal carcinoma in situ or breast cancer. Although this seems to be cost-effective and is similar to mammographic screening costs, formal analyses should be performed that factor a patient's actual risk of breast cancer and quality-adjusted life-years. Clancy J. Clark, M.D. Keith T. Paige, M.D. General Surgery Virginia Mason Medical Center Seattle, Wash.