Bilateral risk-reducing mastectomy – surgical procedure, complications and financial benefit

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Bilateral risk-reducing mastectomy – surgical

procedure, complications and financial benefits

Obustronna mastektomia redukująca ryzyko – procedura

chirurgiczna, powikłania i zysk finansowy

Piotr Gierej

^1,2ABDEF

, Bartosz Rajca

^3BEF,

Adam Górecki-Gomoła

^3BEF

1Department of Breast Cancer and Reconstructive Surgery, The Maria Sklodowska-Curie National Research Institute of Oncology in Warsaw, Poland; Head: prof. Zbigniew Ireneusz Nowecki MD PhD

2Department of Plastic Surgery, SPSK im. Prof. W. Orłowskiego CMKP in Warsaw, Poland; Head: prof. Bartłomiej Noszczyk MD PhD

3Faculty of medicine, University of Warsaw, Poland

Article history: Received: 27.12.2020 Accepted: 05.03.2021 Published: 11.03.2021

ABSTRACT: Risk-reducing mastectomy is a recognized prophylactic treatment for women at high and very high risk of breast cancer development in many countries. In surgical treatment, mastectomy with simultaneous reconstruction is preferred. The most common method is simultaneous reconstruction with the use of implants, but an equivalent method with a comparable or lower complication rate is simultaneous reconstruction with own tissues, taking into account free tissue flaps. The patient should be informed about the high risk of complications, possible deterioration of the life quality and high rate of corrective reoperations. In order for this form of the most effective and financially measurable health prophylaxis to be actually implemented, it is necessary to rationally evaluate the procedure and differentiate its costs depending on the type of reconstruction performed.

KEYWORDS: breast reconstruction, prophylactic mastectomy, risk-reducing mastectomy

STRESZCZENIE: Mastektomia redukująca ryzyko jest uznanym postępowaniem profilaktycznym w grupie kobiet wysokiego i bardzo wysokiego ryzyka zachorowania na raka piersi w wielu krajach. W leczeniu chirurgicznym preferuje się mastektomię z równoczasową rekonstrukcją. Najczęściej wykonywana jest równoczasowa rekonstrukcja z użyciem implantów, ale równoważną metodą – i o porównywalnym lub niższym odsetku powikłań – jest równoczasowa rekonstrukcja tkankami własnymi, z uwzględnieniem wolnych płatów tkankowych. Należy poinformować pacjentkę o wysokim ryzyku powikłań, możliwym pogorszeniu jakości życia i wysokim odsetku ponownych zabiegów korekcyjnych. Aby taka forma najskuteczniejszej i wymiernej finansowo profilaktyki zdrowotnej była rzeczywiście realizowana, konieczna jest racjonalna wycena procedury i zróżnicowanie jej kosztów w zależności od rodzaju przeprowadzonej rekonstrukcji.

SŁOWA KLUCZOWE: mastektomia profilaktyczna, mastektomia redukująca ryzyko, rekonstrukcja piersi

Authors’ Contribution:

A – Study Design B – Data Collection C – Statistical Analysis D – Manuscript Preparation E – Literature Search F – Funds Collection

is knowledge of both the surgeon performing the procedure and the patient regarding different aspects of the proposed procedure. It is an invasive procedure, the consequences of which are ir- reversible, affecting not only the physical but also the psychological aspect of the patient. Due to the lack of a surgical technique that would ensure removal of the entire glandular tissue, despite its performance, there is a minor risk of developing breast cancer.

Hence, instead of the commonly functioning concept of prophylactic mastectomy, risk-reducing mastectomy is a more adequate and postulated concept. However, in appropriately selected groups of patients, and with the appropriate surgical skills, it brings tangible benefits to women in high and very high-risk groups.

TYPES AND EXTENT OF RISK-REDUCING

MASTECTOMY

Risk-reducing mastectomy can be performed both without reconstruction and with immediate or delayed reconstruction. The scope of total excision of the breast gland and the type of reconstruction are not substantially different as compared to those operated

ABBREVIATIONS

ADM – acellular dermal matrix

AOTMiT – The Agency for Health Technology Assessment and Tariff System

DCIS – ductal carcinoma in situ

ESMO – European Society for Medical Oncology MRI – magnetic resonance imaging

NCCN – National Comprehensive Cancer Network

NICE – The National Institute for Health and Care Excellence NSM – nipple sparing mastectomy

RRM – risk reducing mastectomy SSM – skin sparing mastectomy

INTRODUCTION

Risk-reducing mastectomy, commonly known as prophylactic mastectomy, is the most effective primary prevention of breast cancer. It should be remembered that there are no absolute indications for such a procedure. The key to making the right decisions

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due to breast cancer. Obviously, in the case of elective prophylactic procedures, there are no limitations resulting from the use of adjuvant therapies that may influence such decisions in cases of diagnosed breast cancer. In the guidelines of various organizations regarding breast reconstruction after surgery, e.g. prophylactic mastectomy, it was indicated that:

1. AHS (Alberta Health Services – Canadian recommendations from 2017 for breast reconstruction) [1]:

•

There are several types of reconstruction available and there is currently insufficient scientific evidence to favor either. This decision should be made by the surgeon and the patient, after having carefully informed them about all the advantages and disadvantages of each type of reconstruction;

•

Immediate breast reconstruction should be considered in patients after prophylactic mastectomy;

2. NVPC [2] (Netherlands Society for Plastic and Reconstructive Surgery – 2017 Dutch guidelines):

•

When performing prophylactic mastectomy, immediate breast reconstruction is preferred;

3. ESMO [3] (European Society for Medical Oncology) – when performing risk-reducing mastectomy

•

Both the skin-sparing mastectomy and the nipple- sparing mastectomy are an acceptable alternative to total mastectomy (class of recommendation: III; level of evidence: C);

•

Immediate breast reconstruction should be offered (class of recommendation: V; level of evidence: C);

4. NICE [4] – All women considering bilateral RRM should have an opportunity to discuss the options for breast reconstruction (immediate, delayed) with a surgeon specializing in oncoplasty or having appropriate skills.

These recommendations are consistent in that breast reconstruction should be considered in every patient undergoing risk-reducing mastectomy.

There is no evidence of benefit in the routine use of sentinel lymph node biopsy in reducing the risk of mastectomy, and it is not currently recommended [5]. The risk of finding invasive cancer in the postoperative preparation is low. In one study [6], DCIS was found in 6% of prophylactic mastectomy cases (9/151), and atypical changes in 5.3%. There was no evidence of invasive cancer cells.

In 2.1% (2/96) of patients, DCIS cells were found in the margin obtained from the retroareolar region – the authors suggest the need for routine sampling. However, these results indicate the need for very thorough diagnostics before surgery. Due to the relatively low percentage of recurrences within the nipple areola complex in patients operated on for breast cancer, reported at the level of 0.9–2.0% (follow-up period up to 41 months), RRM sparing the nipple areola complex in order to obtain better aesthetic results seems to be a safe procedure [7–9]. There is also no scientific evidence against the safety of a possible transfer of the nipple

areola complex as a free graft to another area of the body and its delayed transplantation – the decision seems to depend on ana- tomical conditions and remains at the discretion of the surgeon.

In one of the studies, in 33 collected and examined nipple areola complexes reducing the risk after mastectomy, no atypical le- sions, pre-invasive or invasive cancer were found in any case [10].

There is also no evidence against the safety of prophylactic mastectomy with reconstruction using own tissues [11]. Although most of the simultaneous reconstructions in prophylactic mastectomy are performed with the use of implants, if the patient prefers reconstruction with their own tissues or due to other indications, procedures using own tissues for breast reconstruction may be performed. In the case of using free flaps, a standard and most frequently performed procedure is the split DIEP flap, used on both sides. Nestle-Krämling et al. [11] indicate the specificity of performing preventive mastectomy and suggest performing these procedures in highly specialized, certified centers ("breast reconstruction center"). Despite the complexity of the procedure, the total risk of complications of such procedures does not differ from reconstruction with the use of implants, and in specialized centers it is even slightly lower [12]. There is currently no evidence against the simultaneous bilateral prophylactic mastectomy.

In the case of indications for prophylactic ovariectomy and prophylactic mastectomy with simultaneous reconstruction of the lower abdominal flaps (TRAM, SIEA, DIEP), the sequence of tre- atments does not affect the risk of postoperative complications from the abdominal wall, including the occurrence of abdominal hernia [13]. Earlier prophylactic ovariectomy may occasionally affect the inability to use a DIEP flap, and earlier reconstruction with a lower abdominal flap may be associated with a longer du- ration of prophylactic ovariectomy.

At present, there are no uniform guidelines regarding the method of reconstruction and all methods are acceptable (retro-pectoral, pre-pectoral, synthetic mesh or ADM, single/two-stage) [14]. Each of these methods has both advantages and drawbacks (Tab. I.). Likewise, each has its supporters and opponents. It seems that reaching consensus will be difficult, and the method of reconstruction should be individualized depending on anato- mical conditions (breast size, ptosis, skin laxity, subcutaneous tissue thickness) and the patient's preferences. There is no evidence that a particular procedure is overwhelmingly superior.

Simultaneous single-stage reconstruction with a target implant (most often in the pre-pectoral technique) is currently enjoying a growing interest (increase from 17.4% in 2013 to 45.1% in 2016), in favor of a two-stage reconstruction (expander and then implant), with a quite constant, low percentage of < 10% of the primary simultaneous reconstruction with autologous tissues [15].

However, we will have to wait for distant results of pre-pectoral reconstructions.

In cases of prophylactic mastectomy, there are no contraindica- tions for autologous adipose tissue transplantation for aesthetic improvement or breast reconstruction. Although in cases of breast cancer, preclinical studies have suggested the possibility of stimulating the growth of breast cancer and metastasis with autologous adipose tissue transplants, several studies have shown that they do not increase the risk of cancer recurrence when used as a deferred procedure in breast reconstruction [14].

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Tab. I. Types of immediate breast reconstructions – advantages and disadvantages.

Type of breast reconstruction Advantages Disadvantages

1. Alloplastic • easier procedure

• lack of donor site morbidity

• the risk of complications is similar, but the aesthetic effect worsens over time

• in the case of prosthesis infection, reconstruction failure most often

1A. Depends on the type of implant:

– with saline–filled implants • the possibility of the one stage reconstruction in the sub-muscle position

• the ability to change the size of the implant

• lower implant life

• tend to feel firmer than silicone implants

• needs valve removal

– with final implant (usually silicone implant) • one stage reconstruction, most often prepectoral • limited possibilities of submuscular reconstruction, depending on the size of the prosthesis

– with tissue expander • usually sub-muscle position

• possibility of correction during the second stage with a final prosthesis

• needs to be replaced during second procedure

• risk of leakage 1B. Depends on implant position:

– prepectoral (subcutaneous implant position)

• technically simpler

• faster recovery period

• one stage procedure

• no interference with the muscles

• natural early efect

• long-term effect? (depending on the quality of the cutaneous flap, the risk of ptosis and excessive skin laxity), implant more visible and palpable

• in the case of ischemia of the skin, a higher risk of implant

• most often it requires an additional synthetic mesh or loss collagen matrix

• due to the weight of the implant and the risk of ptosis, the size of the implant is usually not exceeded over 500–550cc

– sub-muscle (covering with the greater pectoral muscle and the serratus anterior muscle)

• the surface of the implant is less visible

• the ability to adjust the size of the implant depending on the needs (when expander used)

• the possibility of correcting the position of the prosthesis during the second stage

• the procedure usually requires two stages (first with an expander, in some cases one stage is possible with small prosthesis volumes)

• greater pain

• longer recovery period

• higher risk of an overgrown of connective tissue capsule

– partially sub-muscle (partially covered with the pectoral muscle, the lower field stabilized with synthetic mesh/ collagen matrix or a subcutaneous flap after epidermis removal)

• technically simple

• the possibility of one-stage reconstruction even in cases of larger breasts

• early natural effect

• stabilization of the breast fold and the position of the prosthesis depending on the overgrowth of the used material with fibrous tissue

• additional cost in the case of a synthetic mesh/collagen matrix

• the optimal absorption time of the synthetic material has not been established

2. Autoplastic (from own tissues)

• natural shape and drooping of the breasts

• a change in the appearance of the flap with age and weight change

• higher level of satisfaction with aesthetic effects

• stable aesthetic effect over time

• more difficult procedures

2A. Simultaneous reconstruction with DIEP flaps

(most often autoplastic procedure) • as above

• additional abdominal plastic surgery • longer operation time

• complications and additional scarring of the donor site 2B. Goldilocks mastectomy (reduction in patients

with breast hypertrophy – filling of the skin envelope with an excess dermal-subcutaneous flap, without the use of implants)

• no additional cuts and complications of the donor

• the use of a standard reduction techniquesite

• the possibility of applying in a few cases of patients with hypertrophic and ptotic breasts

• limited volume of the breast being restored 2C. Latissimus dorsi muscle flap reconstruction • in the RRM plays a marginal role, most often reserved for rescue procedures in the event of skin complications 3. Depending on the extent of the mastectomy:

3A. SSM – skin sparing mastectomy (removal of the nipple–areola complex, leaving the skin envelope)

• safe (low risk of skin necrosis)

• complete removal of milk ducts – lower risk of breast cancer development

• technically simple

• worse aesthetic effect

• the need to reconstruct the nipple–areola complex

3B. NSM – nipple sparing mastectomy • good aesthetic effect

• technically more difficult

• higher risk of skin ischemia / necrosis

• higher risk of breast cancer (lactiferous ducts left behind the nipple)

3C. SRSM – skin-reducing subcutaneous mastectomy

• performed with ptotic breasts

• the possibility of using the excess skin flap for additional covering of the implant

• free graft of the nipple-areola complex can be used to reduce the risk of complications

• when transferring the areola on dermal–subcutaneous flap, the need for periareolar incision increasing the risk of ischemia

3D. ASM – areola sparing mastectomy (with nipple removal)

• good aesthetic effect

• lower risk of breast cancer – complete removal of the

lactiferous ducts • no prominence of the nipple

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COMPLICATIONS

Prophylactic mastectomy is not a risk-free operation. Although it is planned and the patient is being prepared for the procedure, the risk of complications is relatively high. Each patient considering this type of procedure must be informed about this risk.

In one publication [16], with a high reported complication rate, the most common were: skin necrosis/ischemia – 29.9%, wound infection – 17.0%, excessive blood loss – 9.0%, hematoma – 8.1%, excessive lymphatic drainage – 7.6%, wound dehiscence – 3.6%.

Thromboembolic complications occurred in 1.3%. Complications occurred in 51.6% of patients in total. 10% of patients required removal of the implant (follow-up period 10–156 months) due to skin complications, and 45% of the patients required reoperation after reconstruction with the use of an implant (including 29.14% due to connective tissue capsule and 14.7% due to implant rupture). In another retrospective study with an extremely high complication rate, 56.7% of patients required reoperation in a 9-month follow- -up, and the ischemic rate was 69.3% [17].

Of note, an increased risk of complications is associated with BMI increase (73% with BMI > 30 vs. 15% with BMI < 25) and a higher risk, especially of skin ischemia, is observed in smokers (68% vs.

16%) [18]. However, there are significant discrepancies between the reported complication rates, and the patient groups are often not homogeneous. In a retrospective Elmi cohort study [18] (N-5740, 5290 bilateral RRM, 78% with simultaneous reconstruction), early complications within 30 postoperative days were 7.9%, infections in total in 4.6%, wound dehiscence in 0.9%, pneumonia in 0.1%, pul- monary embolism in 0.2%, bleeding requiring transfusions in 2.4%, sepsis in 0.4%, and thromboembolism in 0.2%.

The type of incision used in mastectomy affects the risk of ischemic complications of the skin or the nipple areola complex. It is the highest for the periorbital incision [15, 19]. In a systematic review and meta-analysis (51 studies, 9975 NSM), the mean complication risk for the periareolar incision was estimated to be 18.1% versus 6.82% for the inframammary fold incision [15].

The risk of complications is lower with skin-sparing mastectomy (SSM) compared to nipple-sparing mastectomy (NSM) [20]. In a retrospective analysis, Van Verschuer compared 2 groups of patients: a group of 25 women after skin-reducing mastectomy (50 SSM) with an average follow-up of 65 months and a group of 20 women (39 NSM) after nipple-sparing mastectomy with a follow-up period of 27 months. Comparing the groups, total complications were found in 38% and 60%, respectively. Infectious complications in 25% and 15%, skin ischemia in 0% and 35%, and reoperations in 29% and 50%. 56% of NSM patients were dissatisfied with the loca- tion of the complex.

Prophylactic mastectomy with autologous tissue, as compared to implant reconstruction, is an equivalent option. The majority of complications are related to the technique of subcutaneous mastectomy and the associated necrosis or ischemia of the skin flaps of the breast or the nipple areola complex. The number of total complications does not differ from implant reconstruction, and sometimes it is lower in some aspects [12]. Bletsis et al. [12] compared prophylactic mastectomies with reconstruction with autologous tissues or implants (214 vs. 176 breasts). The difference

between the total number of complications was statistically insi- gnificant (13.6% vs. 18.7%, p = 0.162), although there was a higher percentage of minor complications (11.2% vs. 18.8%, p = 0.036), seromas (2.3% vs. 7.4%, P = 0.018) and breast inflammation (1.9%

vs. 13.1%, p < 0.001) in the group of patients reconstructed with implants. These results are consistent, especially with regard to the risk of local infectious complications, with the observations in other publications [21–24]. As expected, in the case of bilateral simultaneous reconstruction with free lower abdominal flaps, the complication rate is slightly higher than in the unilateral procedure [25], but mainly in terms of minor local surgical complications and cardiovascular complications (thromboembolic complications 1.8% vs. 0.3%, myocardial infarction 0.2% vs. 0%, arrhythmia 3.8%

vs. 1.4%). The number of vascular complications in the (arterial or venous) flaps was similar (3.6% vs. 2.7%).

The experience of the operator and the center seems to be the key. In one of the publications in which subcutaneous mastectomies were performed with nipple-areola complex preservation and simultaneous reconstruction using various techniques in 428 patients (657 breasts, including 245 prophylactic breasts), a significant contribution of increasing experience in reducing the risk of complications was indicated [9]. Postoperative complications were compared in the series of the first 100 operated breasts and the next 557. There was a decrease in the percentage of nipple-areola complex necrosis from 13% to 1.8%, implant loss from 13% to 8.4%, and skin ischemia from 15 to 11.3%, with the percentage of infectious complications at a similar level (14% vs. 18.5%).

The AOTMiT report [26] draws attention to the high percentage of reoperations after bilateral risk-reducing mastectomy – between 30.4% and 64%. This percentage is higher in studies with a longer follow-up period. The incidence of all postoperative complications in the Carbine review [27] is in the range of 29–49.6%. Although most women are satisfied with the aesthetic effects of the procedure performed (60–75%), the percentage of women dissatisfied with the aesthetic effect varies, depending on the publication, between 6%

and even 40%. Patients dissatisfied with the aesthetic effects often report being poorly informed, and finally 15.5% of them would not decide to have the procedure again. Such large discrepancies again strongly suggest the role of the center's experience, the need for detailed information about the procedure, as well as careful selec- tion and careful qualification of patients, in whom the risk of poor aesthetic effect is high. It is also necessary to inform about the ne- gative impact on sexual relations, which may affect up to 44% of patients. The overall level of anxiety and stress after risk-reducing mastectomy is statistically significantly lower and is stable over time (after 9 years, p = 0.01). Research shows that the majority of women are satisfied with the decision to take RRM (61–100%) [28]. At the same time, many of them indicate very strong psychological stress, the lack of psychological support before and after the procedure, and a lack of understanding of the surgical procedure itself. Pro- phylactic mastectomy most often affects women aged 30–40 years, although the procedure is performed at almost any age. The AOT- MiT report [26] emphasizes the need to refer to a psychologist or a social worker before performing RRM with immediate breast reconstruction. Such necessity is also indicated by the guidelines of some organizations [2, 4]. It seems that women after prophylactic mastectomy should receive the same care as women after mastectomy for therapeutic purposes, including rehabilitation financed from public funds, which will enable them to recover.

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in cases with distant metastases. Importantly, in 2007, more than 6 times more money was spent on treatment of patients aged 30–34 years than on treatment of patients aged over 85 years (56.000 vs. 7.500 PLN) [31]. It is common knowledge that women with a family history of breast cancer develop it statistically at a younger age than in cases of sporadic breast cancer. The indirect costs of breast cancer include the loss of potential revenues from the public finance sector. In the report by Nojszewska [32], the estimated costs of raw production exceeded six times the costs of treatment of the analyzed breast, cervical and ovarian cancers.

The total indirect costs of treatment of only these three cancers, the effect of which is a reduction in the potential GDP generated in the economy in Poland amounted to PLN 3.75 billion in 2010 and increased to PLN 4.41 billion in 2014, which corresponded to a value of 0.24–0.26 percent of the country's GDP. Indirect costs of breast cancer dominated in the analysis, constituting 67–70%

of the costs of these three analyzed diseases. For comparison, the National Health Fund has allocated PLN 623.5 million to PLN 695.7 million annually for the treatment of breast, cervical and ovarian cancers in 2010–2014. Treatment of breast cancer also en- tails a heavy burden on the household budget, reaching over PLN 20.000 per year [33]. Out of this, as much as PLN 14.6 thousand represents the costs of medicines, materials and medical equip- ment, transport, etc. borne directly by patients. The loss of inco- me is also significant, amounting to PLN 6.2 thousand annually.

The absence of patients with advanced breast cancer from work (temporary or permanent incapacity to work) causes an average loss of GDP by approximately PLN 35 thousand, and for patients under 45, even PLN 68.619. Taking into account the total costs (di- rect and indirect) of potential breast cancer treatment in the group of women targeted to RRM (many times higher than the current procedure valuation), this procedure is highly justified from the economic point of view. Unfortunately, as always, the valuation of the procedure remains a controversial issue. It seems that it does not take into account modern methods of breast reconstruction and reconstruction with own tissues.

CONCLUSIONS

The procedure of bilateral risk-reducing mastectomy appears to be a medically and economically rational prophylactic procedure. In principle, simultaneous reconstruction should be proposed, although the scope of the procedure and the possible type of reconstruction must be individualized. Due to a very high risk of complications as for a prophylactic procedure, the qualification should be undertaken very carefully, and the procedure should be performed by people experienced in breast reconstructive surgery.

For the procedure to be introduced and popularized successfully, it is necessary to perform a rational evaluation of the service, taking into account the type of reconstruction.

LONG-TERM POSTOPERATIVE FOLLOW-UP

According to the ESMO guidelines [3], there is no evidence that any follow-up regimen is necessary, effective, or cost-effective in patients after surgery to reduce the risk of cancer. Hence, there is currently no recommended schedule of follow-up of patients after surgery reducing the risk of cancer (class of recommendations: V; level of evidence: C). On the other hand, annual MRI or ultrasound examination is acceptable in the case when more glandular tissue is left.

The NICE guidelines [4] do not recommend offering follow-up to patients who have undergone bilateral prophylactic mastectomy intended for people at high risk of developing breast cancer.

Also, the AHS guidelines [1] indicate that there is no scientific evidence to support routine breast reconstruction mammography and such management is not recommended. In the case of iden- tifying suspicious changes in the reconstructed breast, a surgical consultation is necessary to determine a further procedure. Re- garding the lifetime of the implant, although magnetic resonance imaging can detect rupture of the implant shell, there is no evidence that radiological screening of asymptomatic reconstructed breasts is justified.

IS IT WORTH IT?

According to the AOTMiT [26], there are approximately 100 thousand carriers of the BRCA mutation in Poland. According to the report on the implementation of the National Programs to Pre- vent and Control Cancer, BRCA1/BRCA2 mutations were detected in 620 people in Poland in 2017. The number of women from the highest-risk families covered by the program was 6.148, and the number of women from high-risk families was 10.798. The number of breast tumors detected at that time was 115. Poland is one of the countries with a very low percentage of prophylactic mastectomies in the population of women with the BRCA1/2 mutation. In the group of 9 countries (Austria, Canada, France, Isra- el, Italy, Norway, the Netherlands, Poland and the USA), Poland came last [29]. Only 2.7% of women with a confirmed BRCA1/2 mutation had a prophylactic mastectomy at that time, compared to the average of 18% (in the Netherlands 32.7%, USA 36.3%). Le- t's hope that the introduction of RRM to the guaranteed benefits package in 2019 will improve these statistics.

According to one of the reports [30], the estimated medical costs of breast cancer treatment (including surgery, systemic treatment, radiotherapy, follow-up), depending on the stage, range from PLN 45.891 for cancer without nodal metastases, to PLN 107.791 for cancer with axillary lymph node metastasis, up to PLN 116.591

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Word count: 5185 Page count: 7 Tables: 1 Figures: – References: 33 10.5604/01.3001.0014.7878 Table of content: https://ppch.pl/issue/13784

Some right reserved: Fundacja Polski Przegląd Chirurgiczny. Published by Index Copernicus Sp. z o. o.

The authors declare that they have no competing interests.

The content of the journal „Polish Journal of Surgery” is circulated on the basis of the Open Access which means free and limitless access to scientific data.

This material is available under the Creative Commons – Attribution-NonCommercial 4.0 International (CC BY-NC 4.0).

The full terms of this license are available on: https://creativecommons.org/licenses/by-nc/4.0/legalcodeode Piotr Gierej MD PhD; Department of Breast Cancer and Reconstructive Surgery, The Maria Sklodowska-Curie National Research Institute of Oncology in Warsaw; Roentgena street 5, 02-781 Warsaw, Poland; Phone: +48 502648161;

E-mail: piogierej@wp.pl

Gierej P., Rajca B., Gorecki-Gomola A.: Bilateral risk-reducing mastectomy – surgical procedure, complications and financial benefit; Pol Przegl Chir 2021; 93(3): 48-54

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