By Dr. Constance M Chen
According to the National Cancer Institute, the risk of breast cancer is approximately 12% for women in the general population, which means that one in eight women will develop breast cancer at some point in her life. But the risk is considerably greater for women who inherit a mutation in the BRCA1 or BRCA2 gene that prevents the gene from performing its proper function, which is to produce proteins that help suppress tumors. That risk is 60% for those with a BRCA1 mutation and 45% for those with a BRCA2 mutation. As more women become aware of these risks, those who test positive for the harmful mutations face the difficult decision of whether to reduce their risk by undergoing bilateral prophylactic mastectomy – preventive removal of both breasts.
In making this decision, each woman must weigh various medical and personal factors. When she evaluates reconstruction options, she'll discover that we've made remarkable strides in our ability to create a soft, warm, natural breast that spares the nipple and areola and produces an outstanding aesthetic result. But women may wonder if surgery that conserves the nipple will leave in place breast tissue that might be subject to cancer. The experience of thousands of women and their healthcare providers has been that nipple-sparing mastectomy is safe for women with harmful BRCA mutations and now a major study has confirmed that this surgery essentially eliminates the risk of cancer in the reconstructed breast.
National Cancer Institute data indicates that women with harmful BRCA mutations who undergo prophylactic mastectomy can reduce their risk of developing breast cancer by 95%. These risk-reduction statistics are compelling, and the new report confirms that even women with BRCA mutations can confidently select a nipple-sparing mastectomy that produces a reconstructed breast that is virtually indistinguishable from an unoperated-on breast.
The report, “Oncologic Safety of Prophylactic Nipple-Sparing Mastectomy in a Population With BRCA Mutations” by Jakub et al, was published in the Journal of the American Medical Association in September 2017. It details a multi-institution, retrospective study with a substantial sample size in which not a single BRCA patient who underwent nipple-sparing mastectomy developed cancer after a mean follow-up time of five years.
The risk model for BRCA mutations predicted that without prophylactic mastectomy, 22 new primary breast cancers would have been expected during that period. This is an impressive and statistically significant result. Nipple-sparing mastectomy essentially eliminated all expected cases of breast cancer in the study population. The report concludes that nipple-sparing mastectomies are “highly preventive” against breast cancer in a BRCA population.
The report confirms the belief of oncologists and surgeons that nipple-sparing mastectomy in BRCA patients is safe because most cancers develop deep in the breast, in the terminal duct lobular units, and the dermis and epidermis of the nipple and areola are not affected.
Candidates for nipple-sparing mastectomy must be screened to rule out the presence of disease in the nipple. Women with symptoms such as bloody nipple discharge, which might indicate the potential for disease in the nipple itself, would not be appropriate candidates. But for women with no indication of disease in the breast, including those with BRCA mutations, a prophylactic nipple-sparing mastectomy essentially eliminates the risk of breast cancer and offers the opportunity for state-of-the-art breast reconstruction that maintains both the woman's health and her sense of self.