Prophylactic nipple-sparing mastectomy is as effective at preventing breast cancer as more invasive surgeries, according to a multi-institution study presented at the annual meeting of the American Society of Breast Surgeons.1
These findings can be reassuring to women who are BRCA mutation carriers that mastectomies in which the nipple and surrounding skin are preserved, resulting in more natural-looking breasts after surgery, safely reduce their breast cancer risk.
“Nipple-sparing mastectomy is gaining wide acceptance because of its superior cosmetic results, but pockets of the medical community remain skeptical that it is the right choice for the BRCA [mutation] population,” said James Jakub, MD, a breast surgeon at Mayo Clinic in Rochester, Minnesota, and lead author of the study. “This is the largest study of its kind to address the controversy, and to show that nipple-sparing mastectomy is as effective at preventing breast cancer as traditional mastectomy.”
To determine the incidence of breast cancer in BCRA-positive women who underwent prophylactic nipple-sparing mastectomy, researchers studied outcomes for 348 patients who collectively underwent 551 mastectomies performed at 9 institutions between 1968 and 2013.
The study included 203 women who underwent prophylactic bilateral mastectomy, and 145 patients who had one breast removed prophylactically after cancer occurred in the other breast.
None of the patients who underwent a bilateral nipple-sparing mastectomy developed breast cancer at any site after an average of 3 to 5 years of follow-up. No breast cancers developed in the retained skin, nipples, or lymph nodes on the side of the prophylactic procedure. Seven women died from breast cancer during follow-up; in all of those cases the patients had a previous or concurrent breast cancer at the time of surgery and their stage IV disease was attributed to that cancer.
Nipple-sparing mastectomies leave the nipple, areola, and breast skin intact. Their use is increasing and has gained acceptance as a safe option for patients with breast cancer.
In 2009, approximately 8% of mastectomies performed at Mayo Clinic were nipple-sparing, and that number more than tripled to approximately 30% just 5 years later. Jakub reported that that number is increasing further. Still, controversy has remained over whether the procedure is appropriate for women with BRCA mutations, who risk of breast cancer is 50% to 60% by age 70 years and up to 80% over a lifetime.
“The BRCA population has a genetic mutation in all the cells of their body that predisposes them to breast cancer,” Jakub said. “We know that a majority of breast cancers originate in the breast ducts, so it might seem counterintuitive to leave behind the nipple and the ducts associated with the nipple when you are trying to reduce the risk of this disease.”
Several studies have shown the procedure is safe among BCRA mutation carriers, but some physicians have been waiting for more evidence. Jakub believes the study results offer further proof that nipple-sparing mastectomy is effective in preventing breast cancer among women carrying the BRCA mutation and should be offered when they consider prophylactic surgery.
“There is no question that this option of nipple-sparing mastectomy can often provide an outstanding cosmetic result and may make it easier for women who are at risk to take this preventive measure,” Jakub said. “Though the nipple is preserved, it unfortunately will not have stimulation or arousal. Despite that, studies looking at the impact of risk-reducing surgery on quality of life, sexual satisfaction, and intimacy, suggest that being able to preserve aesthetics and body image can improve all of these factors.”
1. Jakub J. Multi-institutional study of the oncologic safety of prophylactic nipple-sparing mastectomy in a BRCA population. Oral presentation at: American Society of Breast Surgeons 17th Annual Meeting; April 13-18, 2016; Dallas, Texas.