Quality of life and other outcomes of breast reduction surgery

Author: Tamara Crittenden

Crittenden, Tamara, 2020 Quality of life and other outcomes of breast reduction surgery, Flinders University, College of Medicine and Public Health

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The effectiveness of breast reduction surgery for women with symptomatic mammary hypertrophy has been established by previous studies but questions have remained about whether restrictions to accessing breast reduction surgery, based on particular criteria, are appropriate. This thesis is a comprehensive body of work on the health benefits of breast reduction surgery, evidence for restrictions and cost-effectiveness.

The introductory chapter of this thesis presents a review of the literature relating to the health burden associated with breast hypertrophy; and the reported health gains following breast reduction surgery. A review of the assessment of outcomes following surgery through post-operative complications and patient-reported outcomes is included. This chapter highlights the inconsistencies and limitations described in existing research studies. The final section of Chapter 1 details the increasing importance of economic evaluations in weighing up the costs and benefits of medical interventions.

This thesis reports on research which aimed to provide insight into the health burden of breast hypertrophy and the clinical- and cost-effectiveness of breast reduction surgery in improving health-related quality of life (HRQoL) within the Australian healthcare system. Chapter 2 describes a prospective outcome study in Australian women before and up to 12-months after breast reduction surgery. This study details the recruitment of a control group of women with breast hypertrophy who did not undergo surgery for comparison. HRQoL was assessed using validated patient-reported outcome measures (PROMs) including the Short Form-36 (SF-36) and Multi-Dimensional Body-Self Relations Questionnaire (MBSRQ). This chapter describes the comparison of outcomes to normative data and demonstrates the effectiveness of surgery in improving HRQoL to levels of the general population. The analysis extended to assess whether women benefit from surgery regardless of participant and clinical factors, including commonly scrutinised factors such as body mass index and resection weight.

Normative data provides a valuable clinical reference point for clinicians to compare scores from women undergoing breast reduction surgery, enabling a better understanding of the health burden of breast hypertrophy and the health benefits of breast reduction surgery. Chapter 3 was designed to derive normative BREAST-Q data from women within the Australian general population; prior to this study, normative BREAST-Q data was limited to a United States population. A comparison of normative population data demonstrated that differences exist when comparing HRQoL between populations, emphasizing the importance of using country-specific normative data wherever possible.

Chapter 4 examines the satisfaction and wellbeing in women before and 12-months after breast

reduction surgery using the BREAST-Q Reduction module. The use of a condition-specific questionnaire in combination with the generic instruments described in Chapter 2 provides a comprehensive assessment of patient-reported outcomes following surgery. Minimal important difference estimates remain undetermined for this PROM and were established in this study to further enhance interpretability and provide clinical relevance of BREAST-Q scores.

Limited evidence exists as to the long-term health benefits of breast reduction surgery. A prospective study establishing the long-term outcomes following breast reduction surgery is detailed in Chapter 5. This study provides a follow-up of women who underwent surgery and were included in the studies described in Chapter 2 and Chapter 4.

Chapter 6 describes the estimation of breast and body volume in women with breast hypertrophy before and after surgery using a series of techniques including anthropometric measurements, water displacement and three-dimensional laser scanning.

In an era of limited healthcare resources, evidence assessing the cost-effectiveness of breast reduction surgery is important to support the maintenance of funding by healthcare decision-makers. Chapter 7 details an economic evaluation of breast reduction surgery within the Australian public healthcare setting. HRQoL gains were assessed using the SF-6D and effectiveness of surgery was measured in terms of cost per quality-adjusted life years (QALYs) gained.

The final chapter summarises the evidence presented in this thesis that breast hypertrophy is a chronic and painful health condition and establishes the effectiveness of surgery in improving HRQoL to levels of the general population. This thesis established that women benefit from surgery regardless of patient and clinical characteristics, including those commonly used as restrictive criteria for access to surgery and insurance coverage in many countries and jurisdictions worldwide. This thesis provides strong evidence to demonstrate the clinical- and cost-effectiveness of surgery, supporting the inclusion of this procedure in publicly funded health systems.

Keywords: Plastic & reconstructive surgery, breast, patient-reported outcomes, quality of life, breast hypertrophy, breast reduction

Subject: Surgery thesis

Thesis type: Doctor of Philosophy
Completed: 2020
School: College of Medicine and Public Health
Supervisor: A/Prof Nicola Dean