Nipple-sparing Mastectomy Safe for Women With BRCA Mutations
By Marilynn Larkin, September 20, 2017
NEW YORK (Reuters Health) – Prophylactic nipple-sparing mastectomies (NSMs) are “highly preventive” against breast cancer, even in women with BRCA mutations, and should be offered as a risk-reducing option to appropriate patients, researchers suggest.
“NSM is gaining widespread acceptance because of the superior cosmetic results,” Dr. James Jakub of Mayo Clinic in Rochester, Minnesota, told Reuters Health by email. However, patients and physicians may hesitate to opt for the procedure when women have BRCA mutations.
To investigate the safety and efficacy of the intervention, Dr. Jakub and colleagues reviewed outcomes, from 1968 to 2013, of prophylactic NSM in patients with BRCA mutations from nine institutions.
Women who underwent contralateral risk-reducing mastectomy were included, but only the prophylactic breast was considered in the analysis.
As reported in JAMA Surgery, online September 13, the team analyzed outcomes of 548 risk-reducing NSMs in 346 patients (median age, 41), including 202 (58.4%) who underwent bilateral prophylactic NSMs and 144 (41.6%) who had a unilateral risk-reducing NSM secondary to cancer in the contralateral breast.
In all, 201 patients had BRCA1 mutations and 145 had BRCA2 mutations. By a median and mean follow-up of 34 and 56 months, respectively, no breast cancers had developed in the ipsilateral nipple-areolar complex, skin flaps, subcutaneous tissue, mastectomy scar, chest wall, or regional lymph nodes on the side of the risk-reducing procedure, nor did breast cancer develop in any patients who underwent bilateral risk-reducing NSM.
Using risk models for BRCA1/2 mutation carriers, the team calculated that an estimated 22 new primary breast cancers were expected to have occurred without prophylactic NSM. The procedure resulted in a significant reduction in breast cancer events, according to the authors, “suggesting that NSM is an oncologically effective approach, even in this high-risk population.”
Dr. Jakub observed, “It is worth noting that one quarter of the patients had more than five years of follow-up, six had over 30 years of follow-up, and the longest follow-up after surgery was 36 years.”
However, he added, “unfortunately, the breast mound, including the nipple areolar complex, will be without sensation, stimulation or arousal (after NSM). Like all operations, NSM with reconstruction does have risks, including not being successful and loss of the nipple areolar complex.”
“Prophylactic mastectomy is not the only option for patients with a genetic mutation, and is not 100% protective, but for those considering preventive mastectomies NSM should be discussed as an option,” he concluded.
Three experts not involved in the study provided their views in emails to Reuters Health.
Dr. Jan Wong of East Carolina University in Greenville, North Carolina, coauthor of an accompanying editorial, said, “Because there is some technical variation in how NSM is performed and because these are germline mutations, any residual breast tissue remains at risk for undergoing malignant degeneration. I believe these women warrant continued surveillance.”
Dr. Kazuaki Takabe, Clinical Chief of Breast Surgery at Roswell Park Cancer Institute in Buffalo, New York, noted, “Obligatory caveats are that this is a retrospective study with selection bias from world-leading institutions, and the median follow-up period is only three years, which is too short to evaluate the oncological outcome of breast cancer.”
“That said, the paper tells us that when NSM is done right to the right patients, there will be no immediate local recurrence from the nipple. This is in agreement with what we see in our clinics,” he concludes.
Dr. Constance Chen of New York Eye and Ear Infirmary of Mount Sinai in New York City said, “The caveats are that reasonable criteria need to be established for patients to be appropriate candidates for NSM. For example, a patient with bloody nipple discharge indicating that there is potential disease in the nipple itself should not undergo NSM.”
“I have extensive experience with BRCA patients who elect to undergo prophylactic NSM and immediate breast reconstruction,” she added. “My experience is that (the procedure) is safe, and this article confirms my experience.”