A. M. White1, C. R. Thomas1, G. M. Ahrendt1, M. Bonaventura1, C. De La Cruz2, E. J. Diego1, M. Gimbel2, R. Johnson1, V. Nguyen2, K. Shestak2, A. Soran1, P. F. McAuliffe1, K. P. McGuire1,3 1University Of Pittsburgh,Surgical Oncology/Surgery,Pittsburgh, PA, USA 2University Of Pittsburgh,Plastic Surgery,Pittsburgh, PA, USA 3University Of North Carolina At Chapel Hill,Surgical Oncology/Surgery,Chapel Hill, NC, USA
Introduction: The oncologic outcomes of breast conservation surgery (BCS) versus mastectomy (TM) have been well studied, with no significant difference identified in long term overall survival. Additionally, there is a growing body of evidence showing equivalent oncologic outcomes between nipple-sparing mastectomy (NSM) and TM, with up to 10 years of follow-up. In contrast, oncologic and cosmetic outcomes of NSM and BCS have never been directly compared. Our study addresses this critical need by comparing NSM to BCS and TM. We hypothesize that there is no significant difference in recurrence, survival or cosmesis between these groups.
Methods: This is a retrospective review of a prospectively maintained, IRB approved (PRO12110356) database of all NSM performed at a single institution from 2009 to 2015. 116 patients undergoing NSM were compared to 115 undergoing BCS and 124 undergoing TM. 56% (n=67) of patients undergoing TM had reconstruction. Subjects were matched by age, tumor size and histology. Patients were excluded if they had metastatic cancer, severe or uncontrolled systemic disease, or if they were not eligible for BCS. The primary endpoint, locoregional recurrence rate, was defined as ipsilateral breast, chest wall or axillary recurrence within the follow-up period. Secondary endpoints included total (locoregional and distant) recurrence rate, overall survival rate and cosmetic outcome. Cosmetic outcome was determined using a 4 point Likert scale (excellent, good, fair, poor) by physician extenders as part of our yearly Wellness Clinic appointment or at post-operative visits. Outcomes were compared using Pearson Chi square test.
Results: Average (± standard deviation) age was 48±9 years. Tumor size was <2cm for 82%, 2-5 cm for 15%, and >5 cm for 3% of patients. Histology was invasive ductal cancer for 51%, invasive lobular cancer for 9% and ductal carcinoma in situ for 40% of patients. Follow-up was 15±10, 27±15 and 34±21 months in the NSM, BCS and TM groups respectively. No significant difference was seen in locoregional recurrence rate between NSM (0.9%), BSC (0.8%), and TM (1.6%) or in total recurrence rate, NSM (7.8%), BCS (7.8%), and TM (5.6%) (p=0.7). Additionally, overall survival rates, (98.3%, 96.5% and 98.4%, p=0.6), were similar between NSM, BCS and TM, respectively. Cosmetic outcomes after NSM (excellent/good 99%, fair 1%) was equivalent to BCS (excellent/good 98.6%, fair 1.3%) and TM with reconstruction (excellent/good 98.3%, fair 1.6%), p=1.
Conclusion: A growing number of patients with breast cancer who are candidates for BCS elect to undergo NSM. However, there is no literature directly comparing NSM to BCS in oncologic and cosmetic outcome. Our study demonstrated no significant difference in recurrence rate, overall survival rate or cosmesis between NSM, BCS, and TM. These results may offer a framework for dialogue to assist surgical candidates with informed decisions.