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Nipple-Sparing Mastectomy Is as Safe as Traditional Mastectomy—Commentary

10/08/17 Faisal Al-Mufarrej, MD, FACS, Assistant Professor of Plastic and Reconstructive Surgery, Wayne State University School of Medicine; Mary Ann Kosir, MD, FACS, Professor of Surgery and Oncology, Wayne State University School of Medicine

Surgery for breast cancer sometimes involves removing the breast (mastectomy). Doctors typically then do reconstructive surgery to recreate the breast, but many women remain unhappy with the appearance of the reconstructed breast because there is no nipple. In the past, doctors have been concerned that leaving the nipple during a mastectomy (nipple-sparing mastectomy, or NSM) might allow the cancer to return in the nipple tissue.

Some doctors have used NSM for more than a decade, but there have not been studies that compare NSM with other types of mastectomies in a strict protocol (for example, assigning half of a group of women to have a standard mastectomy and half to NSM). Because NSM has been done so often, studies now examine results in women who had NSM because a protocol is no longer likely.

The Massachusetts General Hospital recently reported very encouraging results in 311 breast cancer patients who had a nipple-sparing mastectomy. Doctors followed these women for an average of 51 months, and saw no instances of cancer coming back in the nipple-areola area. This study did not report on the cosmetic results or quality of life, but other reports have already shown better appearance and improved quality of life after NSM when compared to a standard mastectomy. 

What this latest report does is two-fold: First, it favorably reports the use of NSM on a broader group of women, and secondly, it describes the accepted technique for safely removing as much breast tissue as possible from the back of the nipple-areola area.   

Can everyone have a nipple-sparing mastectomy?

No, NSM is not for everyone. Women who can undergo NSM must not have the following: 

  • Inflammatory breast cancer
  • Cancer directly involving the nipple-areola area
  • Nipple discharge associated with the cancer
  • Advanced cancer that includes the skin of the breast

In the report from Mass General, doctors also did not include women whose breasts were sagging or very large because there would be too much space left over after removal of the breast tissue to allow for safe reconstruction, and it would also misplace the nipple on the newly reconstructed breast. However, new techniques for NSM are being developed for women with such breasts.

In recent years, doctors have been interested in expanding the number of women with breast cancer who can undergo NSM.  While women with genetic mutations (such as the BRCA mutation) have undergone NSM for prevention of breast cancer, the question is whether a patient with a genetic mutation AND cancer could undergo NSM.  In this report, there were 33 patients who did. But in order to conclude that NSM is as safe as a standard mastectomy for such patients, a larger number of breast cancer patients with the BRCA mutation need to be studied. There is also interest in offering NSM to patients who underwent chemotherapy (neoadjuvant) before surgery (this treatment is usually given to patients with advanced and more aggressive cancers).

It is reassuring that current guidelines from the National Comprehensive Cancer Network (NCCN) support the use of NSM for the types of patients in the Mass General report.  The American Society of Breast Surgeons (ASBrS) is analyzing a registry of patients who underwent NSM, so more confirmation is forthcoming. ASBrS also issued technical details about how the operation should be performed.

This report is very important. NSM can be offered to breast cancer patients who meet the requirements based on their breast cancer and appearance as reported here.  Although NSM started as a procedure to prevent breast cancer, it is now commonly used to treat it. Over the past two decades, the procedure has become more accepted and more widely applicable. In the future, there may be even more categories of patients who would be able to undergo NSM. When considering a mastectomy, every patient should ask her surgeon about the nipple and whether NSM is a safe treatment option.