Saving Nipples During Mastectomy Does Not Increase Risk of Cancer Recurrence

Leaving nipples intact during mastectomy can cosmetically improve breast reconstruction results without raising the risk of cancer recurrence, a study has shown.

Published online in July by the Journal of the American College of Surgeons, the study included 297 women who underwent nipple-sparing mastectomy (NSM) and then were followed for five years, the period during which treated breast cancer is most likely to recur. The women had undergone a total of 311 mastectomy procedures at Massachusetts General Hospital (MGH), in Boston (14 of them having bilateral mastectomies). Among those, investigators found a 5.5 percent cancer recurrence rate at a median follow-up of 51 months. The percentage of patients who were alive and without breast cancer recurrence was 95.7 percent at three years and 92.3 percent at five years.

None of the recurrences in the study population involved the nipple. The authors added that no breast cancer developed at the nipple in any of the other 1,871 NSM procedures performed at MGH between 2007 and 2016 for either cancer treatment or prevention. The nipple is an uncommon site for breast cancer to start, even in high-risk patients, the institution stated in a press release.

The recurrence rate logged in the study is comparable to the rate that occurs after standard mastectomy, noted principal investigator Barbara L. Smith, M.D., Ph.D., a surgical oncologist and director of the Breast Program at MGH.

The authors added that 3.7 percent of the recurrences reported in the study (10 of a total 17) were locoregional, meaning that they involved the chest wall and/or axillary lymph nodes and had the potential to be treated and cured with surgery and a combination of chemotherapy and radiation.

“More women are requesting NSM because of the superior cosmetic results, but doctors don’t want to take any chances with breast cancer patients’ safety for the sake of cosmetic improvement,” Smith said. “Our study, which has one of the longest reported follow-ups after therapeutic NSM in the United States, provides additional support that it’s safe to leave the nipple intact during mastectomy with only a few exceptions.”

Advantages of Nipple-Sparing Mastectomy

While standard mastectomy removes the whole breast, NSM removes the breast tissue but leaves the skin, nipple and areola intact, paving the way for more natural-looking reconstruction. Sensation is lost when the nerves to the nipple are cut during the procedure, but choosing NSM can have psychosocial benefits, Smith said. “Often,” she said, “a woman feels more whole when she keeps her nipple.”

Another advantage of NSM is that it can facilitate immediate breast reconstruction that is completed along with the mastectomy procedure.

“Not only does the breast look more natural after NSM, a woman who still has fully intact breast skin can often choose to have a single-stage breast reconstruction with an implant, rather than needing a tissue expander (an inflatable breast implant) to stretch the skin over several months,” Smith said.

Immediate reconstruction is most likely to be achievable in women who have small or moderate-sized breasts, added Suzanne B. Coopey, M.D., a breast surgical oncologist at MGH and an author on the study. “At Mass General Hospital,” she said, “we have had a lot of success with this approach.”

Who Is Eligible?

Women with any subtype of breast cancer, or who face increased risk for the disease due to genetic susceptibility, are candidates for the NSM procedure unless they have confirmed cancer in the nipple and areola; locally advanced breast cancer involving the skin; inflammatory breast cancer; or very large or sagging breasts, which would result in an unacceptable location of the nipple, MGH explained in the release.

More than three-quarters of the women in the study had stage 0 or 1 breast cancer, and the rest had stage 2 or 3 disease. Twenty-three percent of cases were ductal carcinoma in situ, in which cancer cells have not spread beyond the milk ducts, and the remaining 77 percent of participants had invasive cancer.

Stage 4 patients were not included in the study because “surgery in this setting is controversial and usually not recommended, and treatment is usually systemic,” Coopey said.

Potential Complications

After NSM, surgeons remove the tissue directly under the nipple and test it to make sure no cancer has been left behind. If a biopsy shows cancer, surgeons remove the nipple and/or areola in an outpatient procedure, and this occurred in 6.4 percent of study participants, or 20 of 311 breasts.

“As part of the informed consent process prior to NSM, patients are made aware that the nipple may need to be removed if the nipple margin is positive,” Coopey said. “Most patients are willing to take this small chance in an attempt to save their nipple. In a prior study, we found that the excised nipple only contains cancer 28 percent of the time and is negative for malignancy 72 percent of the time. Because the nipple is insensate, the nipple can often be removed under local anesthesia or no anesthesia in the office by the plastic surgeon several weeks after surgery. In most cases, the nipple is removed and the areola is retained, so the cosmetic appearance is still acceptable to most patients. If not, they always have the option of nipple reconstruction in the future.”

It’s also possible, although rare, that the retained nipple will die. In the study, that happened in 1.7 percent of cases. “Full-thickness nipple necrosis requires excision of the nipple,” Cooley explained. “If a necrotic nipple is not excised, it can lead to infection and loss of implant reconstruction.”

A concern associated with immediate reconstruction in general is that the results will be imperfect. One reason is that swelling during surgery can make it difficult for surgeons to anticipate the final size of reconstructed breasts.

However, Coopey noted that surgical revisions are no more common at her facility with immediate versus postponed reconstructions. “At Mass General Hospital, we have a revision rate of 21 percent for a direct-to-implant approach,” she said, “which is similar to that of tissue-expander reconstructions.”

Coopey said that patients don’t need to worry that retaining their nipples will interfere with surveillance for future breast cancers.

“Routine surveillance after mastectomy for breast cancer includes only a clinical examination of the retained breast skin and nodal basins,” she said. “Saving the nipple does not interfere with this surveillance, but the retained nipple areola complex should be thoroughly inspected as part of this surveillance.”

What to Ask Your Surgeon

Any patient planning to undergo a mastectomy should be offered a consultation with a plastic surgeon to discuss reconstruction options, Coopey said. During that discussion, the authors suggest, “Women planning a mastectomy should ask their surgeon whether they are eligible for a nipple-sparing operation.”

Whether surgeons are comfortable performing that procedure may depend on whether they work at high-volume, academic cancer centers, as the practice is relatively new.

“We started offering NSM at Mass General in 2007, but the procedure really started gaining popularity around 2011,” Coopey said. “As with any procedure, it is important to ask your surgeon about their qualifications and if they were trained in NSM and how many procedures they have performed.”

She added that both NSM and breast reconstruction for patients with cancer or heightened genetic risk are typically covered by health insurance plans.

“Recent studies suggest that single-stage implants are more cost-effective than two-stage reconstruction with tissue expanders in terms of overall cost, and also reduced number of clinic visits,” she said.