Oncologic safety of prophylactic nipple-sparing mastectomy in a population with BRCA mutations: A multi-institutional study

James W Jakub, Anne Warren Peled, Richard J. Gray, Rachel A. Greenup, John V. Kiluk, Virgilio Sacchini, Sarah A. McLaughlin, Julia C. Tchou, Robert A. Vierkant, Amy C Degnim, Shawna Willey

Research output: Contribution to journalArticle

31 Citations (Scopus)

Abstract

IMPORTANCE Nipple-sparing mastectomy (NSM) offers superior cosmetic outcomes and has been gaining wide acceptance; however, its role among patients with BRCA mutations remains controversial. OBJECTIVE To report on the oncologic safety of NSM and provide evidence-based data to patients and health care professionals regarding preservation of the nipple-areolar complex during a risk-reducing mastectomy in a population with BRCA mutations. DESIGN, SETTING, AND PARTICIPANTS We retrospectively reviewed the outcomes of 9 institutions’ experience with prophylactic NSM from 1968 to 2013 in a cohort of patients with BRCA mutations. Patients with breast cancer were included if they underwent contralateral risk-reducing mastectomy; however, only the prophylactic side was considered in the analysis. Patients found to have an occult primary breast cancer at the time of risk-reducing mastectomy, those having variant(s) of unknown significance, and those undergoing free nipple grafts were excluded. MAIN OUTCOMES AND MEASURES The primary outcome measure was development of a new breast cancer after risk-reducing NSM. Three reference data sources were used to model the expected number of events, and this was compared with our observed number of events. RESULTS A total of 548 risk-reducing NSMs in 346 patients were performed at 9 institutions. The median age at NSM was 41 years (interquartile range, 34.5-47.5 years). Bilateral prophylactic NSMs were performed in 202 patients (58.4%), and 144 patients (41.6%) underwent a unilateral risk-reducing NSM secondary to cancer in the contralateral breast. Overall, 201 patients with BRCA1 mutations and 145 with BRCA2 mutations were included. With median and mean follow-up of 34 and 56 months, respectively, no ipsilateral breast cancers occurred after prophylactic NSM. Breast cancer did not develop in any patients undergoing bilateral risk-reducing NSMs. Using risk models for BRCA1/2 mutation carriers, approximately 22 new primary breast cancers were expected without prophylactic NSM. Prophylactic NSM resulted in a significant reduction in breast cancer events (test of observed vs expected events, P < .001). CONCLUSIONS AND RELEVANCE Nipple-sparing mastectomies are highly preventive against breast cancer in a BRCA population. Although the follow-up remains relatively short, NSM should be offered as a breast cancer risk-reducing strategy to appropriate patients with BRCA mutations.

Original languageEnglish (US)
Pages (from-to)123-129
Number of pages7
JournalJAMA Surgery
Volume153
Issue number2
DOIs
StatePublished - Feb 1 2018

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Nipples
Mastectomy
Safety
Mutation
Population
Breast Neoplasms
Information Storage and Retrieval
Cosmetics
Patient Care

ASJC Scopus subject areas

  • Surgery

Cite this

Oncologic safety of prophylactic nipple-sparing mastectomy in a population with BRCA mutations : A multi-institutional study. / Jakub, James W; Peled, Anne Warren; Gray, Richard J.; Greenup, Rachel A.; Kiluk, John V.; Sacchini, Virgilio; McLaughlin, Sarah A.; Tchou, Julia C.; Vierkant, Robert A.; Degnim, Amy C; Willey, Shawna.

In: JAMA Surgery, Vol. 153, No. 2, 01.02.2018, p. 123-129.

Research output: Contribution to journalArticle

Jakub, JW, Peled, AW, Gray, RJ, Greenup, RA, Kiluk, JV, Sacchini, V, McLaughlin, SA, Tchou, JC, Vierkant, RA, Degnim, AC & Willey, S 2018, 'Oncologic safety of prophylactic nipple-sparing mastectomy in a population with BRCA mutations: A multi-institutional study', JAMA Surgery, vol. 153, no. 2, pp. 123-129. https://doi.org/10.1001/jamasurg.2017.3422
Jakub, James W ; Peled, Anne Warren ; Gray, Richard J. ; Greenup, Rachel A. ; Kiluk, John V. ; Sacchini, Virgilio ; McLaughlin, Sarah A. ; Tchou, Julia C. ; Vierkant, Robert A. ; Degnim, Amy C ; Willey, Shawna. / Oncologic safety of prophylactic nipple-sparing mastectomy in a population with BRCA mutations : A multi-institutional study. In: JAMA Surgery. 2018 ; Vol. 153, No. 2. pp. 123-129.
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N2 - IMPORTANCE Nipple-sparing mastectomy (NSM) offers superior cosmetic outcomes and has been gaining wide acceptance; however, its role among patients with BRCA mutations remains controversial. OBJECTIVE To report on the oncologic safety of NSM and provide evidence-based data to patients and health care professionals regarding preservation of the nipple-areolar complex during a risk-reducing mastectomy in a population with BRCA mutations. DESIGN, SETTING, AND PARTICIPANTS We retrospectively reviewed the outcomes of 9 institutions’ experience with prophylactic NSM from 1968 to 2013 in a cohort of patients with BRCA mutations. Patients with breast cancer were included if they underwent contralateral risk-reducing mastectomy; however, only the prophylactic side was considered in the analysis. Patients found to have an occult primary breast cancer at the time of risk-reducing mastectomy, those having variant(s) of unknown significance, and those undergoing free nipple grafts were excluded. MAIN OUTCOMES AND MEASURES The primary outcome measure was development of a new breast cancer after risk-reducing NSM. Three reference data sources were used to model the expected number of events, and this was compared with our observed number of events. RESULTS A total of 548 risk-reducing NSMs in 346 patients were performed at 9 institutions. The median age at NSM was 41 years (interquartile range, 34.5-47.5 years). Bilateral prophylactic NSMs were performed in 202 patients (58.4%), and 144 patients (41.6%) underwent a unilateral risk-reducing NSM secondary to cancer in the contralateral breast. Overall, 201 patients with BRCA1 mutations and 145 with BRCA2 mutations were included. With median and mean follow-up of 34 and 56 months, respectively, no ipsilateral breast cancers occurred after prophylactic NSM. Breast cancer did not develop in any patients undergoing bilateral risk-reducing NSMs. Using risk models for BRCA1/2 mutation carriers, approximately 22 new primary breast cancers were expected without prophylactic NSM. Prophylactic NSM resulted in a significant reduction in breast cancer events (test of observed vs expected events, P < .001). CONCLUSIONS AND RELEVANCE Nipple-sparing mastectomies are highly preventive against breast cancer in a BRCA population. Although the follow-up remains relatively short, NSM should be offered as a breast cancer risk-reducing strategy to appropriate patients with BRCA mutations.

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