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Nipple-sparing mastectomy reduces breast cancer risk for BRCA–positive women
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Prophylactic nipple-sparing mastectomy did not compromise risk reduction among women who harbor a BRCA mutation, according to a retrospective analysis presented at the American Society of Breast Cancer Surgeons Annual Meeting.
“A growing body of knowledge suggests that the nipple surface is composed of skin cells while the ductal tissue where cancer arises is located deeper within the breast,” James Jakub, MD, section head of breast and melanoma surgery at Mayo Clinic in Rochester, Minnesota, said in a press release. “With a growing understanding of the nature of nipple tissue itself, modern nipple-sparing surgical techniques and a growing body of research similar to our new study, many surgeons believe this is an effective risk-reducing approach for the BRCA population.”
Nipple-sparing mastectomy procedures have been rising in popularity due to improved cosmetic results, according to the researchers. However, the role of this procedure in the BRCA–positive population remains controversial, thus prompting researchers to determine the incidence of breast cancer developing in BRCA–positive women following a prophylactic nipple-sparing mastectomy.
The analysis included data from 348 patients who underwent 551 risk-reducing nipple-sparing mastectomies between Jan. 1, 1960 and Dec. 31, 2013.
Researchers included patients with a cancer diagnosis who opted for a contralateral risk-reducing mastectomy but only analyzed the risk-reducing breast. Bilateral prophylactic nipple-sparing mastectomies were performed in 203 patients, and 145 patients underwent a unilateral risk-reducing nipple-sparing mastectomy secondary to a previous or current breast cancer in the contralateral breast.
Two-hundred four women harbored a BRCA1 mutation and 144 had BRCA2 mutation.
The development of a new primary breast cancer in the surgical field following a risk-reducing nipple-sparing mastectomy served as the primary endpoint.
During a median follow up of 34 months (mean, 56 months), no breast cancers developed in the ipsilateral skin flaps, subcutaneous tissue, nipple areolar complex, mastectomy scar, chest wall, or regional lymph nodes on the side of the prophylactic procedure. There were no cancers at any site for patients who underwent a bilateral risk-reducing nipple-sparing mastectomy.
Twelve patients died during the follow-up period — seven died of breast cancer, all of whom had a previous or synchronous contralateral breast cancer at the time of their prophylactic procedure and their stage IV disease was attributed to the known cancer. Three women died of ovarian or fallopian tube cancer and two died from other causes.
These data show risk-reducing nipple-sparing mastectomies are effective, although lack of sensitivity remains an issue.
“Modern nipple-sparing mastectomies dissect the nipple and areola in an extremely thin layer close to the skin. Unlike prior techniques that left a thick layer of breast tissue below the nipples, the process is almost akin to a skin graft,” Jakub said. “Assuming the surgery is complication-free, with today's nipple-sparing techniques, women with BRCA can look forward to very effective risk reduction with a very superior cosmetic outcome. However, the nipple will unfortunately not have stimulation or arousal.” – by Nick Andrews
Reference:
Jakub J, et al. Multi-institutional study of the oncologic safety of prophylactic nipple sparing mastectomy in a BRCA population. Presented at: American Society of Breast Surgeons Annual Meeting; April 13-17, 2016; Dallas, Texas.
Disclosure : HemOnc Today could not confirm the researchers’ relevant financial disclosures at the time of reporting.
Perspective
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Anees B. Chagpar, MD, MSc, MBA, MA, MPH, FACS, FRCS(C)
The work by Jakub and colleagues adds to our growing body of data that nipple-sparing mastectomies are safe in BRCA–mutation carriers. As women are becoming increasingly aware of their genetic risk, and genetic counselors are finding more mutations that put patients at increased risk, more patients are opting for this cosmetically appealing approach to reduce their risk for developing breast cancer.
In their study, Jakub and colleagues found that no patients developed breast cancer in 34 months of follow-up. Seven patients succumbed of breast cancer during the follow-up period, but these were all patients who either had a previous or coexisting malignancy, and their demise was attributed to that. No cancer was found in the mastectomy skin flap or nipple of the prophylactic mastectomy.
Although these data suggest that nipple-sparing mastectomy is safe as a prophylactic option, it should be noted that they excluded patients who were found to have occult malignancy in the prophylactic mastectomy and those with variants of unknown significance. It would have been interesting to see whether the results would have been significantly different if these patients were included. One would surmise that since the majority of variants of unknown significance turn out to be benign, that this would only confirm nipple-sparing mastectomies to be safe in this population.
Further, although the deaths that were noted were in patients who had previous disease, one would think that if disease was occult, it was likely of low volume and less likely to metastasize. Although these assumptions cannot be validated in the current study, they would make sense in light of the body of literature that exists in this arena.
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