More Proof: Nipple-Sparing Mastectomy Safe for BRCA Carriers

Nick Mulcahy

April 21, 2016

Although prophylactic nipple-sparing mastectomy has increasingly gained acceptance among breast cancer patients because of the superior cosmetic results, it's use in high-risk BRCA patients remains controversial.

Now new data — from the largest study of its kind — add to the evidence that the approach appears to be safe and effective in this setting, at least in the short term.

The findings were highlighted during a presscast last week from the 17th Annual Meeting of the American Society of Breast Surgeons in Dallas.

"Leaving the nipple behind gives patients pause," said lead study author James Jakub, MD, a breast surgeon at the Mayo Clinic in Rochester Minnesota. But most breast cancers develop in the ducts, away from the nipple, he explained.

There is an element of risk, because nipple-sparing mastectomies leave the nipple, areola, and breast skin intact, Dr Jakub acknowledged. But breast cancers in this area after mastectomy are rare, he noted.

Still, any risk is a matter of heightened concern in BRCA carriers, who have a high risk for breast cancer — 50% to 60% by age 70, and up to 80% over a lifetime.

Leaving the nipple behind gives patients pause.

To evaluate the incidence of breast cancer in BCRA-positive women, Dr Jakub and his colleagues studied outcomes in 348 patients who, collectively, had undergone 551 prophylactic nipple-sparing mastectomies performed at nine institutions from 1968 to 2013. In this cohort, there were 204 patients with BRCA1 mutations and 144 with BRCA2 mutations.

All of the surgeries assessed were prophylactic; however, 145 patients had had a single breast removed prophylactically that was secondary to a current or previous breast cancer (which was removed therapeutically). The remaining 203 patients had had both breasts removed prophylactically. Patients found to have an occult cancer in a prophylactically removed breast were excluded from the study.

Median follow-up was 34 months.

None of the patients who had undergone bilateral nipple-sparing mastectomy developed breast cancer at any site during follow-up.

All seven women who died from breast cancer had a current or previous breast cancer at the time of prophylactic surgery, and their stage IV disease was attributed to that pre-existing cancer, not to a cancer that developed after preventive surgery. Another three women who died had ovarian or fallopian tube cancer, and two died from other causes.

A number of studies have shown that the procedure is safe for BCRA carriers, but some clinicians want more evidence, Dr Jakub said.

In one study, researchers found that there was no disease recurrence or occurrence in the nipple or areola in 70 women with BRCA gene mutations who underwent nipple-sparing mastectomy — either therapeutically or prophylactically — at the Massachusetts General Hospital in Boston from 2006 to 2012, as reported by Medscape Medical News. However, the median follow-up time was only 11 months.

In the Mayo Clinic study, follow-up is also "relatively short," Dr Jakub acknowledged, but the "cumulative evidence" supports the risk-reducing procedure as being appropriate, he said.

There are very few contraindications for nipple-sparing mastectomy, said presscast moderator Julie Margenthaler, MD, from Washington University in St. Louis, Missouri.

The procedure is not advisable in women with extra-large breasts for aesthetic and practical reasons, she said. And in women who already have breast cancer, the procedure is contraindicated if the cancer is in the nipple or within 1 inch of the nipple.

At the Mayo Clinic, the use of nipple-sparing mastectomy is on upward trend, Dr Jakub reported. In 2009, about 8% of mastectomies performed there were nipple-sparing; 5 years later, that rate has jumped to approximately 30%.

Notably, the procedure does not preserve the nipple's capacity for stimulation or arousal, Dr Jakub observed.

The study was supported by the National Institutes of Health and the Breast Cancer Research Foundation. Dr Jakub and Dr Margenthaler have disclosed no relevant financial relationships.

17th Annual Meeting of the American Society of Breast Surgeons. Abstract 0173. Presented April 15, 2016.


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