L. A. Dossett1,2, J. Lowe1, W. Sun1, C. Lee1, P. D. Smith1,2, C. Laronga1 1Moffitt Cancer Center And Research Institute,Comprehensive Breast Program,Tampa, FL, USA 2University Of South Florida College Of Medicine,Tampa, FL, USA
Introduction: Nipple-sparing mastectomy (NSM) has rapidly grown in popularity as an approach to treating select patients with breast cancer and for risk reduction in patients with genetic mutations. Mounting data supports the oncologic safety of preservation of the nipple areola complex (NAC), and many presume quality of life (QOL) and other patient-centered outcomes are improved compared to skin-sparing mastectomy (SSM). The predictive factors for selection of NSM by eligible women are largely unknown. We sought to describe demographic, clinical and QOL characteristics of patients declining nipple preservation despite eligibility for NSM.
Methods: Women electing mastectomy with immediate reconstruction and eligible for NSM were prospectively offered inclusion in an IRB-approved nipple sensation and body image/QOL cohort study. Eligibility criteria for NSM: unifocal, small (<3cm) or no tumor (prophylaxis), tumor >2cm from the nipple-areolar complex (NAC), clinically node negative, body mass index (BMI) < 30, estimated breast weight <700 grams, and no or grade 1 ptosis. After signing informed consent, the women self-selected the control arm (SSM) or investigational arm (NSM). Baseline nipple/skin sensation testing and body image/QOL questionnaires were obtained pre-operatively. Demographic, clinical, and QOL data were collected prospectively. Descriptive and comparative statistics were performed.
Results:53 patients were enrolled; 38 (72%) patients selected NSM while 15 (28%) patients selected SSM without NAC preservation. Patients declining NSM despite eligibility were younger (43 ± 10 versus 49 ± 10 years, p=0.05), had a higher BMI (26 ± 4 versus 23 ± 3, p=0.02) and were more likely to have an indication of prophylaxis (strong family history or confirmed genetic carrier) (53% versus 21%, p<0.01). Corresponding to increased BMI, patients declining NSM also had larger breasts by weight (564 v 364 grams, p<0.001) as measured by gross pathology. On baseline QOL evaluation, patients declining NAC preservation were less satisfied with preoperative nipple sensation, as well as the size and appearance of their breast and nipple; these differences were not statistically significant.
Conclusion:Not all women eligible for NSM select this approach. Patient characteristics including age, BMI, satisfaction with the natural breast, and indication for mastectomy may predict patient preference and motivation with regards to preservation of the NAC during mastectomy. Patient motivation and acceptance of future cancer risk may explain these differences. Ongoing research regarding patient preferences may clarify decisions for NAC preservation and improve overall patient outcomes.