Is Prophylactic Nipple-Sparing Mastectomy Advised for Women with BRCA Mutations?

By Constance M. Chen, MD, MPH

Approximately 12% of women, or one in eight, will develop breast cancer at some point in their lives, according to the National Cancer Institute. However, the risk is substantially higher for women who inherit a mutation in the BRCA1 or BRCA2 gene that prevents the gene from producing proteins that help suppress tumors. The lifetime risk can be as high as 86% for patients with one of the BRCA mutations. 

As more women become aware of these risks, many who test positive for the harmful BRCA mutations are compelled to decide whether to reduce their risk by undergoing bilateral prophylactic mastectomy – preventive removal of both breasts. And in making that decision, there are other variables to consider as well,

Women have to look at various personal and medical factors. When considering and assessing reconstruction options, women learn that great strides have been made in breast reconstruction by using your own tissue to create a soft, warm, natural breast. Combining natural tissue breast reconstruction with a mastectomy that preserves all the skin including the nipple-areola complex allows for the best possible aesthetic result in which the reconstructed breast may be hard to distinguish from the original breast. 

Some women worry, however, that surgery preserving the nipple has the potential to allow undetected cancer cells to grow undisturbed. In patients with no known disease, however, this is extremely unlikely, In almost all women with harmful BRCA mutations, prophylactic nipple-sparing mastectomy is safe.”

Reducing Risk

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% and confirms that even women with BRCA mutations can undergo a nipple-sparing mastectomy combined with a natural tissue breast reconstruction that produces a reconstructed breast that may be hard to tell apart from a normal breast. These risk-reduction statistics are persuasive and offer hope for many women.

A report published in the Journal of the American Medical Association in September 2017 and titled, “Oncologic Safety of Prophylactic Nipple-Sparing Mastectomy in a Population With BRCA Mutations” by Jakub et al, is 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. 

In the risk model for BRCA mutations it is predicted that without prophylactic mastectomy, 22 new primary breast cancers would have been expected during that period. This is a striking and statistically significant result. What it says essentially is that nipple-sparing mastectomy basically 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 breast oncologists and reconstruction 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. 

Women considering nipple-sparing mastectomy must be screened to rule out the presence of disease in the nipple. If a woman is found to have symptoms such as bloody nipple discharge, which might indicate the potential for disease in the nipple itself, she would not be an appropriate candidate. For women with no sign of disease in the breast, however, including those with BRCA mutations, a prophylactic nipple-sparing mastectomy drastically reduces the risk of breast cancer and sets the stage for a woman to receive state-of-the-art breast reconstruction that allows her to maintain her health and sense of self.          

Constance M. Chen, MD, is a board-certified plastic surgeon with special expertise in the use of innovative natural techniques to optimize medical and cosmetic outcomes for women undergoing breast reconstruction. She is Clinical Assistant Professor of Surgery (Plastic Surgery) at Weill Cornell Medical College and Clinical Assistant Professor of Surgery (Plastic Surgery) at Tulane University School of Medicine. www.constancechenmd.com