New Breast Surgery Comes With Choices

Joy Barrett wasn’t thinking mastectomy. The 39-year-old mother was diagnosed in June 2009 with ductal carcinoma in situ (DCIS), a non-invasive breast cancer. She wanted a lumpectomy to remove the area of DCIS in her left breast, not a mastectomy. Two such surgeries, though, came back showing cancer in the tissue margins and a subsequent MRI hinted at other problem spots. A friend said, “Just get rid of them.” Barrett figured her friend wasn’t as attached to her breasts as she was.

In the weeks following her diagnosis, Barrett talked about her options with a radiation oncologist who told her that even if a third lumpectomy returned with clean margins she would have lost enough tissue from the surgeries to need reconstruction. They also discussed her family history. Barrett tested negative for a BRCA mutation, but two aunts had breast cancer and her mother died of non-Hodgkin lymphoma.

During one of those conversations, Barrett’s oncologist brought up the newer options for reconstruction. Early on, she’d researched “mastectomy” online and saw photos she found unsettling. But the image of those photos differed vastly from the reconstruction choices her oncologist presented.

“This was a different world to me. You’re dealing with the trauma of cancer and then reconstruction opens up a whole new door,” says Barrett.

On her oncologist’s recommendation she traveled from her Pennsylvania home to New Orleans to meet with reconstructive surgeon Robert Allen, MD, and breast surgeon, Alan Stolier, MD, both with the Center for Microsurgical Breast Reconstruction.

Stolier discussed with Barrett her strong family history and her chances for recurrence in the left breast. He also explained that she was at high risk for developing another primary cancer in her right breast.

Encouraged by reconstruction choices but also concerned about going through another cancer diagnosis, Barrett opted for a bilateral mastectomy. However, surgery for each breast was different. On her left breast, the one with DCIS, the nipple couldn’t be saved but enough skin and the areola could be preserved for a reconstructed breast. On the right breast, Barrett had a prophylactic, nipple-sparing mastectomy.

“Frankly, the option of nipple- and skin-sparing mastectomies was a no-brainer. I figured if I’m going under and getting the one removed, I might as well get the other removed,” says Barrett.

Barrett joins a growing number of women who are choosing bilateral mastectomies when the cancer is confined to one breast, essentially combining surgery for cancer resection with prophylactic surgery.

This was a different world to me. You’re dealing with the trauma of cancer and then reconstruction opens up a whole new door.

The first women to choose nipple-sparing mastectomies didn’t have cancer at all. These women chose bilateral prophylactic mastectomy to reduce their risk of cancer. Either they knew their risk was high because of a family history of breast cancer or they had tested positive for a BRCA mutation.

Whether a woman chooses nipple-sparing mastectomy depends on whether her surgeon presents it as an option, it, says Pat Whitworth, MD, of the Nashville Breast Center. Whitworth says he and others have adopted this approach both for patients with breast cancer and for those with a high risk of developing breast cancer.

“We’re doing more and more to traumatize women less and less,” says Whitworth.

In general, here’s how nipple-sparing mastectomy works: The surgeon makes an incision and removes the breast tissue, and tissue under the nipple duct is cored out. Technically, the surgeon has to be skilled enough to remove all breast tissue but preserve the blood supply to the nipple and skin. If the blood supply to the nipple is damaged, the tissue in the nipple can become necrotic and die, in which case the nipple would have to be removed.

If the procedure is part of cancer treatment, surgeons will take tissue under the nipple and do a frozen section right away in addition to a more sensitive test that takes about a week. If either pathology returns with cancer, the nipple has to go.

Critics of nipple-sparing mastectomy worry that leaving the nipple increases recurrence risk if the surgeon doesn’t remove all breast tissue. No randomized trials have directly compared nipple-sparing surgery to a traditional mastectomy and such trials are unlikely. However the published series that do exist—in non-randomized studies—show a low local recurrence rate that is comparable to that of mastectomy, around 5 percent.

“Can we prove that results are the same as skin sparing? No. Because it takes 10, 20, 30 years, but treatment doesn’t wait that long,” says Allen.

Likewise, no physician can guarantee that nipple-sparing mastectomy will prove as good in terms of risk reduction as traditional mastectomy because no techniques are felt to remove all breast tissue and reduce the chances of cancer recurrence to zero. Over the years, though, surgeons have reported their own cases and there are single institution trials that show recurrence rates for nipple-sparing mastectomy similar to those for traditional mastectomy.

Journal of Clinical Oncology

There’s also caution around whether nipple-sparing mastectomy is safe for those who are BRCA mutation carriers. The largest study, which was published in the , looked at 105 carriers who had undergone prophylactic bilateral mastectomies, one third of which were nipple-sparing. Two patients in the nipple-sparing mastectomy group developed breast cancer during follow-up. In one patient, cancer was found in an axillary lymph node about two years later but not in the breast. The other patient developed DCIS and invasive breast cancer in the residual breast tissue. That case looked to be a mastectomy that left too much normal breast tissue, says David Euhus MD, FACS, the Marilyn R. Corrigan Distinguished Chair in Breast Cancer Surgery at the University of Texas Southwestern Medical School.

“I think the techniques have been developed to the point where we can look a patient in the eyeball and tell them their chance of developing breast cancer after this operation is 5 percent or less,” says Euhus. “You can get breast cancer in a nipple but it’s very, very uncommon.”

Trials such as this have helped surgeons find the right candidate for nipple-sparing surgery. Although each surgeon uses his or her own guidelines, the margin at the nipple must be clear. Some surgeons limit the tumor to a certain size and certain distance from the nipple ducts. Some surgeons won’t do a nipple-sparing mastectomy on women with large, sagging breasts because relocating the nipple-areola complex requires extra surgery. A woman with cancer located in the larger ducts near the nipple, inflammatory breast cancer, or cancer in several areas of her breast would not be a good candidate. Nor are women who are smokers because smoking harms the circulation, increasing the risk of nipple necrosis. Women who’ve undergone breast irradiation are not good candidates either because the skin would be too damaged for reconstruction.

The most important criteria for women who want nipple-sparing mastectomy is access to superb plastic surgical support and reconstruction, says Whitworth. When that’s available women are more likely offered a nipple-sparing mastectomy.

Nipple-sparing mastectomies aren’t perfect, but no reconstruction option is. Sensation can be lost and nipples may lose erectile function, which can affect sexual pleasure.

“Each surgeon has a conversation with a patient about this but I’d venture to guess that some surgeons are more complete about this conversation than others,” says Robert Sener MD, chief of the division of surgical oncology at the USC Norris Comprehensive Cancer Center and Hospital. That’s why Sener will only allow nipple-sparing mastectomy if it’s done as part of an institutional clinical trial. He feels the formality of such a protocol reinforces all aspects of nipple-sparing mastectomy for everyone involved including the patient, institution, surgeons, and caregivers. He wants patients to understand that nipple-sparing mastectomy is not the standard of care, but it is a legitimate step forward.

“Women need to be looking for surgeons who are going to discuss these issues with them. I would venture to say that if you don’t hear this from your surgeon you probably ought to keep looking,” says Sener.