Mari Gallion, an author living in Alaska, is one of a growing number of women with breast cancer to choose nipple-sparing mastectomy.
“You still have your nipples, so that's a part of your breast left that makes it feel more natural and familiar,” she told Healthline.
In a standard mastectomy, the entire breast is removed, along with the nipple and areola.
However, does sparing the nipple increase the risk of cancer coming back?
Not according to new research conducted at Massachusetts General Hospital, and published in the Journal of the American College of Surgeons.
Low risk of breast cancer recurrence
Breast cancer is most likely to recur within the first five years after treatment.
Recurrence can be localized, regional, or distant.
Of 311 study participants who had a nipple-sparing mastectomy (NSM), the rate of recurrence was 5.5 percent. But no recurrences involved the retained nipple or areola. The median follow-up was 51 months.
The recurrence rate is comparable to that of standard mastectomy, Dr. Barbara L. Smith, the study’s principal investigator, said in a press release.
More than three-fourths of the women in the study had stage 0 or stage 1 breast cancer. The rest had stage 2 or 3.
Between 2007 and 2016, 1,871 other NSMs were performed at the hospital. Some were due to breast cancer. Some were performed to prevent breast cancer in high-risk women.
There were no reports of any recurrences involving the nipple. It’s unusual for breast cancer to start in the nipple, even among women who are at high risk.
Option for some, but not all
NSM is a good choice for women who plan on immediate reconstructive surgery.
Women with early-stage breast cancer can be considered, according to Dr. Isabelle Bedrosian, breast surgical oncologist at The University of Texas MD Anderson Cancer Center.
The stage is important because it reflects the extent of disease.
Bedrosian told Healthline that other therapeutic interventions, such as radiation, must also be factored in.
“There are two considerations. One is oncologic. The other has to do with reconstruction. It’s very important that the plastic surgeon weighs in on whether someone is a candidate,” she advised.
“Some of the challenges in nipple-sparing mastectomy are issues from the plastic surgery perspective. I advise women to make sure the plastic surgeon says they can get a good aesthetic outcome. It’s not just the oncologic decisions that matter,” said Bedrosian.
She noted that it’s also a good option for some women who don’t have breast cancer.
“We would consider this for patients who are BRCA mutation carriers. Women getting prophylactic mastectomy are better candidates. They tend to be younger and there’s a greater need to go down this road with them. They don’t need more treatment such as radiation or chemotherapy that might make you pull back. Nipple-sparing mastectomy gives them an emotionally and aesthetically pleasing result,” said Bedrosian.
At Cancer Treatment Centers of America, Dr. Miral Amin is a surgical oncologist, and Dr. Daniel Liu is a plastic and reconstructive surgeon.
Amin told Healthline that physical examinations, imaging, and clinical judgment can help determine if the nipple and areola are involved.
“If there is no involvement of the nipple-areola complex, and as long as it is aesthetic/cosmetically feasible or optimum, then it is a very good option for patients,” she said.
Amin noted that the procedure is not recommended for women with inflammatory breast cancer.
Liu said there are other patients for whom NSM may not be a good choice.
“Patients with unrealistic expectations, patients who are struggling emotionally, active smokers, patients with very large breasts, patients with certain medical comorbidities, or patients who expect full nipple sensation to return may not be good candidates for a nipple-sparing mastectomy,” explained Liu.
“Women with small to medium breast sizes, or have little or no breast ptosis [drooping], would be ideal candidates for nipple-sparing mastectomies,” he continued.
Bedrosian said the emphasis should be on the reconstructive aspect of the procedure.
“Too often, the focus on who is eligible comes from an oncology perspective. We tend to not focus enough attention on selecting patients based on plastic surgeon considerations,” she said.
“The primary reason to do nipple-sparing mastectomy is the aesthetics of the nipple.”
"It’s purely cosmetic and usually has a better result than reconstructing the nipple,” she continued.
But having a mastectomy means nerves will be cut. Bedrosian cautioned that means the nipple will be insensate. It will not have the same sensory function it had before.
Gallion sat that’s true in her case, but she’s still pleased with the result.
“I really prefer my breast that still has the nipple, even though I can't feel anything,” she said.
What could go wrong
There’s no guarantee that NSM will achieve the desired results.
Bedrosian said potential complications, such as infection and healing issues, compare with those of standard mastectomy.
But there’s the potential complication of loss of the nipple.
“It may be devascularized to the point where it ends up dying. Sometimes breast size and shape can impact the results. It’s not always possible to have a good outcome. The nipple can sometimes deviate in ways that look abnormal,” said Bedrosian.
There’s also a chance that cancer cells will be found on the nipple or areola.
In the study, cancer was found in 20 of 311 nipple biopsies. When that happens, the nipple or nipple and areola must later be removed.
That’s what happened to Gallion, who had NSM on both sides. One nipple was found to have cancer. It had to be removed.
According to Bedrosian, monitoring for recurrence after treatment ends is the same as for standard mastectomy.
“Guidelines and recommendations remain regardless of the type of mastectomy, so there’s no need to do more. Data has emerged from Boston that is supportive of those guidelines. Had they seen a high rate of recurrence, we would need more monitoring,” she said.
Amin agreed that there’s no need for extra monitoring.
“They [patients] are routinely followed with physical exam. Imaging, such as ultrasound or MRI of the breast, are ordered based on clinical findings on a case by case basis,” she explained.
Achieving the best results
In women with early-stage disease, where the plastic surgeon sees a good aesthetic outcome, Bedrosian recommends NSM to her patients.
She expects to see more women choosing NSM over standard mastectomy.
“Long-term data suggests outcomes are very good, so we’re likely to see continued growth,” she said. “We’re doing more than in years past and will continue as there’s more awareness in patients and the surgical community itself.”
What if NSM doesn’t work out?
Reconstructive surgery can still provide a good result.
“Nipple-sparing mastectomy results in a superior aesthetic outcome that can be difficult to achieve with standard skin-sparing mastectomy, but we can come very close with modern techniques of autologous reconstruction and 3D nipple-areolar tattooing,” said Liu.
Liu recommends that women discuss the issue with their medical teams to determine if NSM is right the right decision.