— Protective mastectomies that preserve the nipple and
surrounding skin prevent breast cancer as effectively as more
invasive surgeries for women with a genetic mutation called
BRCA that raises their risk of developing breast cancer, a
multi-institution study led by Mayo Clinic found.
research should reassure patients and surgeons that
nipple-sparing mastectomies, which leave women with more
natural-looking breasts than other mastectomies, are a safe
way to reduce breast cancer risk in BRCA carriers, the authors
say. The findings were presented at the annual meeting of the
American Society of Breast Surgeons in Dallas.
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," says study lead author James Jakub, M.D., a
breast surgeon at Mayo Clinic in Rochester, Minn. "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."
determine the incidence of breast cancer in BCRA-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.
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.
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 from 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.
have 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 procedure largely gave way to the modified radical
mastectomy, which left the chest muscles alone. Next came
skin-sparing mastectomies, which preserve an envelope of skin
and allow surgeons to begin breast reconstruction during the
mastectomies leave the nipple, areola and breast skin intact.
Their use is increasing and has gained acceptance as a safe
option in breast cancer patients.
approximately 8 percent of mastectomies performed at Mayo
Clinic were nipple-sparing. Five years later, that fraction
had more than tripled to approximately 30 percent, and Dr.
Jakub says the number is increasing. 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
BRCA population has a genetic mutation in all the cells of
their body that predisposes them to breast cancer," Jakub
says. "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."
studies have shown the procedure is safe among BCRA carriers,
but some physicians have been waiting for more evidence, Jakub
says. He 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.
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," Jakub says. "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."
study’s senior author is Shawna Willey, M.D., of Georgetown
University. The co-authors are Richard Gray, M.D., and Sarah
McLaughlin, M.D., of Mayo Clinic; Anne Peled, M.D., of the
University of California San Francisco; Rachel Greenup, M.D.,
of Duke University; John Kiluk, M.D., of Moffitt Cancer
Center; Virgilio Sacchini, M.D., of Memorial Sloan Kettering;
and Julia Tchou, M.D., Ph.D., of the University of
study was supported by National Institutes of Health
Specialized Program of Research Excellence in Breast Cancer
grant CA116201 and the Breast Cancer Research Foundation.