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