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Special populations: Women with early stage breast cancer
Nipple-sparing mastectomy (NSM) offers better cosmetic results for women who have immediate breast reconstruction (at the same time as their mastectomy). Over the past decade, NSM has gained popularity among surgeons and patients. Studies show that women who keep their own nipples have higher rates of satisfaction and psychological well-being after mastectomy and reconstruction compared to women who lose their nipples. However, little data exists on the long-term risk of recurrence following NSM. New research adds to a growing body of evidence suggesting that risk of recurrence is low after NSM in carefully selected patients with breast cancer. (1/25/18)
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The risk of recurrence following nipple-sparing mastectomy among women with breast cancer.
When women have immediate breast reconstruction (at the same time as mastectomy) their breast tissue is removed, but most of the breast skin is retained to accommodate the reconstruction. A traditional mastectomy also removes the nipple and areola (the darker skin around the nipple). During breast reconstruction the surgeon can also recreate the nipple using the patient’s skin. Tattooing can be used to create the appearance of an areola.
With a nipple-sparing mastectomy (NSM) the surgeon saves the nipple and areola along with the breast skin. However, as a surgeon is performing a NSM, a sample of tissue immediately below the nipple-areola complex is examined by a pathologist. If this sample contains invasive cancer or DCIS, it is considered positive and the nipple is removed often with the areola. The advantage of NSM is cosmetic. NSM mastectomy incisions are usually made in the crease beneath the breast or horizontally from the areola towards the arm, so that after reconstruction, the new breasts appear to be unchanged.
While NSM improves cosmetic and psychological outcomes, many doctors and patients are concerned that sparing the nipple and areola may increase the risk for breast cancer recurrence, especially since the data on long-term risk of recurrence following NSM is limited. This study is important because it adds to a growing body of evidence suggesting that the long-term risk of local (in the tissue surrounding the breast), regional (to the lymph nodes), and distant recurrence (in other parts of the body) following NSM is low.
Results from a large, single-institution study entitled "Oncologic Safety of Nipple-Sparing Mastectomy in Women with Breast Cancer" were published in the September 2017 issue of the Journal of the American College of Surgeons. This study followed outcomes of 2,182 NSMs performed at Massachusetts General Hospital from 2007 to 2016. Long-term outcomes were assessed in 311 patients with stage 0 to III breast cancer; however, 75% of patients followed were stage 0-I.
In this study, the recurrence rate is comparable to that of standard mastectomy matched for stage and adjuvant treatment. It is important to note that breast cancer rarely originates or recurs in the nipple, even in high-risk patients.
For many women who face mastectomy, preserving their nipples allows them to keep an emotionally significant part of themselves that boosts their post mastectomy/reconstruction self-image. And although these women lose their own breast tissue, keeping their own nipples enhances the overall natural appearance of their reconstructed breasts. NSM also offers an added bonus: women can forego having new nipples surgically created as part of their reconstruction process. Anyone who has NSM should understand the risk of the procedure and the risk of recurrence related to retaining their nipples and/or areolas.
Importantly, not all women are candidates for NSM which is determined by the size and shape of the breast, location of the current nipple, previous history of radiation, body mass index, and location and size of the cancer. In this study, the body mass index was low suggesting that most patients were thin. Being overweight or obese may make some women ineligible for NSM.
US News and World Report
Nipple-sparing mastectomies (NSMs) improve post mastectomy cosmetic outcomes for women who have breast cancer or have a high-risk for it. An increasing number of women undergoing mastectomy for breast cancer are candidates for NSM, including those with larger, node-positive cancers who receive neoadjuvant (before surgery) chemotherapy and/or post-mastectomy radiation therapy. As a result, more women are requesting NSM. However, many surgeons and patients are concerned about long-term local recurrence or a new primary breast cancer that could results from breast tissue left beneath the retained nipple.
What is the long-term risk of recurrence following NSM?
Between 2007 and 2012 at Massachusetts General Hospital, 2,182 NSMs were performed in 1,258 patients who were treated for breast cancer or risk reduction. Patients were excluded only if they had cancerous cells in their nipple-areola complex, locally advanced breast cancer in the skin, inflammatory breast cancer, bloody nipple discharge, or if their overly large or droopy breasts would result in undesirable nipple placement on their reconstructed breasts. Data on patients and tumor characteristics; local and systemic treatments; and local, regional and distant recurrence were obtained from patients’ medical records. Outcomes were determined for 311 women with stage 0 to III breast cancer; within this cohort:
Median follow-up was 51 months (ranging from 4 to 101 months). During the follow-up period, 17 patients developed a recurrence. Estimated disease-free survival was 95.7% at 3 years and 92.3% at 5 years. No recurrence involved the retained nipple-areola complex. Among patients with recurrent disease there were:
The authors recognize there may have been a selection bias and that NSM may have been offered disproportionately to patients who had a good prognosis. Although Massachusetts General no longer bases their recommendations for NSM on tumor size, receptor status or stage, these factors may have influenced recommendations during the study period. The researchers also concede that although their follow-up period is long enough to exclude early recurrences with aggressive breast cancer types, it may not be sufficient for determining risk of recurrence for hormone receptor-positive cancers, especially since the predicted risk of recurrence in this population of patients with predominately early-stage disease would be predicted to be low. They are planning a supplemental study with a longer follow-up period to better estimate the risk of recurrence after NSM in these patients.
Women with any of the following conditions are not candidates for NSM: any evidence of cancerous involvement of the nipple and/or areola; tumors close to the nipple-areola complex that could compromise margins; locally advanced breast cancer involving the skin, or inflammatory breast cancer; or large or sagging breasts that would result in an undesirable nipple placement on the reconstructed breast. Furthermore, NSM is not without challenges, and there is no guarantee that everyone who has it will experience ideal or even satisfactory results. Loss of sensation in the nipples is expected after NSM because nerves are cut when tissue is removed. Patients with unrealistic expectations, who struggle emotionally or who expect full nipple sensation to return may not be good candidates for a NSM.
To date, no study has compared recurrence rates between NSM and standard mastectomy by randomly assigning women to one or the other procedure. However, the low local recurrence rate observed in this and other studies suggest that patients who undergo NSM do not have an increased risk of recurrence. Women planning a mastectomy should ask their surgeons whether they are eligible for a nipple-sparing operation, and what benefits and limitations they should expect.
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Smith BL, Tang R, Rai U, et al. “Oncologic Safety of Nipple-Sparing Mastectomy in Women with Breast Cancer.” Journal of the American College of Surgeons. 2017; 225(3):361-365.
“Nipple-Sparing Mastectomy Has Low Rate of Breast Cancer Recurrence.” Press Release from the Journal of the American College of Surgeons.