Nipple-sparing mastectomy may be a good option

Volume 5, Issue 3, 2016

Summary

Technique offers a safe way to reduce breast cancer risk in carriers of the BRCA mutation.

Photograph of James W. Jakub, M.D.

James W. Jakub, M.D.

Mastectomies that preserve the nipple and surrounding skin prevent breast cancer as effectively as do more-invasive surgeries for women with a genetic mutation called BRCA, a multi-institution study led by Mayo Clinic found.

The study findings were presented at the annual meeting of The American Society of Breast Surgeons in April in Dallas.

The research should reassure patients and surgeons that nipple-sparing mastectomies, which leave women with more natural-looking breasts than do other mastectomies, are a safe way to reduce breast cancer risk in carriers of the BRCA mutation, which raises their risk of developing breast cancer.

"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 population," said the study's lead author, James W. Jakub, M.D., a breast surgeon at Mayo Clinic in Rochester, Minnesota. "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 BRCA-positive women who had prophylactic nipple-sparing mastectomies, researchers studied outcomes among 348 patients who collectively had 551 mastectomies performed at nine institutions between 1968 and 2013.

The study included 203 women who had both breasts removed protectively, known as a bilateral mastectomy, and 145 patients who had one breast removed preventively after cancer occurred in the other breast.

None of the patients who had a bilateral nipple-sparing mastectomy developed breast cancer at any site after an average of three to five years of follow-up, the researchers found. No breast cancers developed in the retained skin, nipples or lymph nodes on the side of the prophylactic procedure. Seven women died of 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.

Mastectomy has changed dramatically over the years. The radical mastectomy of the 1950s, '60s, and '70s removed the breast tissue, skin, lymph nodes and underlying muscle. By the 1980s, that approach largely gave way to the modified radical mastectomy, which left the chest muscles alone.

Next came the skin-sparing mastectomy, which preserves an envelope of skin and allows surgeons to begin breast reconstruction during the mastectomy surgery.

A nipple-sparing mastectomy leaves the nipple, areola and breast skin intact. Its use is increasing, and it has gained acceptance as a safe option in patients with breast cancer.

In 2009, approximately 8 percent of mastectomies performed at Mayo Clinic were nipple sparing. Five years later, the nipple-sparing procedure had more than tripled to approximately 30 percent of all mastectomies, and according to Dr. Jakub, the number continues to increase.

Still, controversy remains over whether or not the procedure is appropriate for women with BRCA mutations, who can have a breast cancer risk of 50 to 60 percent by age 70 and up to 80 percent over a lifetime.

"The BRCA population has a genetic mutation in all the cells of their body that predisposes them to breast cancer," Dr. 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 BRCA carriers, but some physicians have been waiting for more evidence. Dr. Jakub believes the study results offer further proof that nipple-sparing mastectomies are 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," Dr. 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."