More women with breast cancer could likely benefit from less-invasive mastectomy, according to research presented May 2, 2019, at the annual meeting of the American Society of Breast Surgeon (ASBrS) in Dallas. The study showed that the surgical procedure, known as a nipple-sparing mastectomy, is a safe option for a subset of patients.
During nipple-sparing surgery, surgeons remove breast tissue but leave the skin, nipple, and areola in place so that they can immediately reconstruct the breast.
The study helps resolve a debate about whether removing a smaller quantity of breast tissue to improve cosmetic results will compromise the chances for a long-term cure or increase surgical complication rates.
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An Increasingly Viable Option for Patients
The study addressed cases in which breast cancer was confined to the breast. The study authors examined outcomes for 769 women who had nipple-sparing mastectomy between 2009 and 2017. The procedure was performed on 1,301 breasts.
Researchers found improvements in the surgery over time. The complication rate fell from 14.8 percent in 2009 to 6.3 percent in 2017, despite the fact that the procedure was offered to more women, including those whose cancer was locally advanced or who had surgical complication risk factors, such as obesity or prior surgery.
The study also found that, after 2013, obesity was no longer associated with negative outcomes.
Overall, one year after surgery, reconstruction was considered a success in roughly 97 percent of cases, according to Judy C. Boughey, MD, a coauthor of the study and a surgeon at the Mayo Clinic in Rochester, Minnesota.
Some patients don’t fare as well with nipple-sparing mastectomy, including women who are recent or current smokers, the study showed. In addition, undergoing radiation before the surgery increased the rate of complications and breast reconstruction failure.
“The expansion of nipple-sparing mastectomy can be reasonably considered, understanding that patient selection is critical,” Dr. Boughey says. It’s important for doctors and patients to discuss the risks and benefits of the procedure, she adds.
Overall, however, the study “clearly demonstrated that careful patient selection and a multidisciplinary team can improve outcomes over time,” says Sarah Blair, MD, a surgical oncologist at the University of California in San Diego and an ASBrS publications committee cochair. Dr. Blair was not involved in the study.
“This data can educate other surgeons on important factors for patient selection as well as techniques to improve outcomes," says Blair.
A Long-Standing Effort Pays Off
For many years, breast surgeons have tried to avoid mastectomy procedures that remove the entire breast. Some patients undergo skin-sparing mastectomy, which preserves as much of the breast skin as possible for reconstruction but involves removal of the nipple and areola, according to BreastCancer.org.
Nipple-sparing surgery offers numerous advantages to patients, including the cosmetic benefits of maintaining the nipple and less breast-tissue removal. The procedure can also be performed at the time of the mastectomy, saving patients from having to return later for reconstructive surgery or procedures to create a nipple.
Nipple-sparing mastectomy has gained traction in recent years, according to a review published in July 2016 in the journal Archives of Plastic Surgery. It was initially recommended for patients with small tumors and small breasts, but surgeons have become increasingly comfortable performing the procedure on many types of patients, says Dr. Boughey.
“Over recent years we have seen an increase in indications among patients with more advanced cancer and patients with more risk factors,” Boughey says.
Nipple Sparing Does Not Appear to Increase Risk
Other studies also point to the benefits of nipple-sparing surgery. Research published in June 2018 in the French journal Annales de Chirurgie Plastique Esthétique reviewed 270 articles on nipple-sparing surgery and found that the procedure does not seem to increase the risk of cancer development.
Moreover, a study published in December 2018 in the journal BJS Open looked at 690 articles and found similar rates of cancer recurrence in nipple-sparing mastectomy (3.9 percent) compared with skin-sparing mastectomy (3.3 percent), although nipple-sparing mastectomy had a higher complication rate — 22.6 percent compared with 14 percent.
"Offering enhanced aesthetics as a result of these surgeries to women who have had a devastating diagnosis is extremely rewarding,” says Tina Hieken, MD, the senior author of the new study and a breast surgeon at Mayo Clinic. “Today, breast cancer patients who are not offered nipple-sparing procedures should ask their surgeons why. As this study shows, these surgeries are proving safe for a broad patient base.”
Other News From the American Society of Breast Surgeons’ Annual Meeting
Patients Undergoing Breast Surgery Use Fewer Opioids Than Expected
Patients rarely use as many opioid painkillers as their doctors provide after hospital discharge from breast cancer surgery, according to a study from researchers at the Cleveland Clinic.
Researchers looked at the average number of pills prescribed by doctors for 100 patients undergoing either lumpectomy, mastectomy, or mastectomy with reconstructive surgery, and recommended that doctors prescribe 10 pills for the lumpectomy patients, 20 for mastectomy patients, and 25 for mastectomy-plus-reconstruction patients. However, they found that patients in the three groups used, on average, 1, 3, and 18 pills, respectively. Forty percent of the patients used no narcotics after discharge. "These were all much less than what was prescribed," says study author Stephanie A. Valente, DO, of the Cleveland Clinic in Ohio. “This suggests that a reduction strategy is feasible.”
Outpatient Mastectomy: It Can Be Done
Two studies confirm that outpatient mastectomy is safe and results in high patient satisfaction. Researchers at Kaiser Permanente looked at 403 outpatient mastectomy procedures and found no difference in emergency department use, hospital readmission, or reoperation in the outpatient versus inpatient patients.
The study is the first large-scale evaluation of surgical home recovery after mastectomy. According to lead study author Brooke Vuong, MD, of Kaiser Permanente South Sacramento Medical Center in California, as of March, 2019, 86 percent of Kaiser mastectomy patients undergo home recovery.
A study from the University of Calgary in Alberta, also found no difference in outcomes when patients recover at home.