ICARE Newsletter Winter 2016

Ask the Expert

The following question was addressed by Dr. Christine Laronga at the Moffitt Cancer Center:

Q. As a BRCA carrier, is it reasonable for me to consider nipple-sparing mastectomy (compared to total mastectomy) to reduce my future risks of breast cancer?

A. One  strategy to manage the high (60-70%) lifetime breast cancer risk among women with a BRCA mutation is risk-reducing bilateral total mastectomy (not subcutaneous mastectomy where a rim of breast tissue is intentionally left on the underside of the breast skin to afford a more natural feel to the reconstructed breast). This procedure reduces the risk of developing breast cancer by 90% or more.  In the past, the entire breast with the overlying nipple and areolar disk was removed when performing this surgery, but more recently there has been an increase interest in preserving the nipple (“nipple-sparing” mastectomy). For many women, the nipple is what defines the breast as a breast.  Prior studies have shown that some patients have psychosocial benefit when the nipple-areolar complex is spared, and for some, the inability to preserve the nipple may be a barrier to even consider mastectomy.

A recent study measured the amount of breast tissue that remains when the nipple is spared with a standard retroareolar margin of 5 mm, and found that this only encompasses 1.3% less of the total at-risk breast tissue among women with BRCA mutations.1 Additionally, two recent studies showed that among BRCA carriers with nipple-sparing mastectomy, fewer than 2% developed subsequent cancers and none were in the nipple-areolar complex.2,3  Furthermore, there was a low rate of complications and no evidence that safety in the cancer setting was compromised.  Although there remains a need for studies with a longer follow-up time, currently available information suggests that it is reasonable for women with a BRCA mutation to consider nipple-sparing mastectomy for both breast cancer risk-reduction and treatment.

From a surgical standpoint, there are different ways of reducing the amount of remaining breast tissue when performing this surgery.  When choosing this surgery, it is important to go to a surgeon who is experienced in this procedure in order to maximize risk reduction and minimize complication rates. 

1Baltzer HL et al. Ann Surg Oncol. 2014 May;21(5):1583-8. PMID: 24526546
2Yao K et al. Ann Surg Oncol. 2015 Feb;22(2):370-6. PMID: 25023546
3Manning AT et al. Br J Surg. 2015 Oct;102(11):1354-9. PMID: 26313374

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