Skip to main content

Advertisement

SpringerLink
Log in

Trends and variation in the use of nipple-sparing mastectomy for breast cancer in the United States

  • Epidemiology
  • Published:
Breast Cancer Research and Treatment Aims and scope Submit manuscript

Abstract

Purpose

For many women, nipple-sparing mastectomy (NSM) provides aesthetic and quality-of-life outcomes superior to skin-sparing mastectomy. Accumulating data suggest that NSM provides similar oncologic outcomes in select breast cancer patients. This study sought to determine national trends in NSM use.

Methods

Using the National Cancer Data Base, 6254 women with breast cancer who underwent NSM between 2010 and 2013 were identified. NSM rates were determined relative to the number of patients who received a mastectomy with reconstruction (n = 114,849). Associations between patient, tumor, and facility characteristics and NSM were assessed using logistic regression.

Results

The rate of NSM increased from 2.9 to 8.0 % between 2010 and 2013. NSM was most commonly performed in academic (adjusted odds ratio [OR] 1.43, p < 0.001) and high-volume (OR 1.59, p < 0.001) breast centers. There was up to a 5.8-fold variation in its delivery between geographic census regions (p < 0.001). Of 1231 hospitals, only 491 (39.9 %) reported performing at least one NSM during the study period. Half of all NSMs were performed by the top 6 % (n = 30) of NSM-performing centers. NSM was associated with small tumor size (p < 0.001), lower tumor grades (p < 0.05), and negative nodal status (p < 0.001). However, half of NSM patients had at least one tumor characteristic that diverged from current (2016) NCCN recommendations for the procedure.

Conclusions

The use of therapeutic NSM is increasing dramatically in the United States, despite recommendations that the procedure be used with caution. As NSM becomes increasingly common, efforts are needed to monitor its long-term oncologic outcomes and to ensure equitable access to it.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Al-Ghazal SK, Fallowfield L, Blamey RW (2000) Comparison of psychological aspects and patient satisfaction following breast conserving surgery, simple mastectomy and breast reconstruction. Eur J Cancer 36(15):1938–1943

    Article  CAS  PubMed  Google Scholar 

  2. Didier F, Radice D, Gandini S, Bedolis R, Rotmensz N, Maldifassi A, Santillo B, Luini A, Galimberti V, Scaffidi E et al (2009) Does nipple preservation in mastectomy improve satisfaction with cosmetic results, psychological adjustment, body image and sexuality? Breast Cancer Res Treat 118(3):623–633

    Article  CAS  PubMed  Google Scholar 

  3. Metcalfe KA, Cil TD, Semple JL, Li LD, Bagher S, Zhong T, Virani S, Narod S, Pal T (2015) Long-term psychosocial functioning in women with bilateral prophylactic mastectomy: does preservation of the nipple-areolar complex make a difference? Ann Surg Oncol 22(10):3324–3330

    Article  PubMed  Google Scholar 

  4. Sisco M, Yao KA (2016) Nipple-sparing mastectomy: a contemporary perspective. J Surg Oncol 113(8):883–890

    Article  PubMed  Google Scholar 

  5. National comprehensive cancer network clinical practice guidelines in oncology: breast cancer (Version 2013.3)

  6. Agarwal S, Agarwal S, Neumayer L, Agarwal JP (2014) Therapeutic nipple-sparing mastectomy: trends based on a national cancer database. Am J Surg 208(1):93–98

    Article  PubMed  Google Scholar 

  7. Amara D, Peled AW, Wang F, Ewing CA, Alvarado M, Esserman LJ (2015) Tumor involvement of the nipple in total skin-sparing mastectomy: strategies for management. Ann Surg Oncol 22(12):3803–3808

    Article  PubMed  Google Scholar 

  8. Boneti C, Yuen J, Santiago C, Diaz Z, Robertson Y, Korourian S, Westbrook KC, Henry-Tillman RS, Klimberg VS (2011) Oncologic safety of nipple skin-sparing or total skin-sparing mastectomies with immediate reconstruction. J Am Coll Surg 212(4):686–693 discussion 693–685

    Article  PubMed  Google Scholar 

  9. de Alcantara Filho P, Capko D, Barry JM, Morrow M, Pusic A, Sacchini VS (2011) Nipple-sparing mastectomy for breast cancer and risk-reducing surgery: the memorial sloan-kettering cancer center experience. Ann Surg Oncol 18(11):3117–3122

    Article  PubMed  Google Scholar 

  10. Tang R, Coopey SB, Merrill AL, Rai U, Specht MC, Gadd MA, Colwell AS, Austen WG Jr, Brachtel EF, Smith BL (2016) Positive nipple margins in nipple-sparing mastectomies: rates, management, and oncologic safety. J Am Coll Surg 222(6):1149–1155

    Article  PubMed  Google Scholar 

  11. De La Cruz L, Moody AM, Tappy EE, Blankenship SA, Hecht EM (2015) Overall survival, disease-free survival, local recurrence, and nipple-areolar recurrence in the setting of nipple-sparing mastectomy: a meta-analysis and systematic review. Ann Surg Oncol 22(10):3241–3249

    Article  Google Scholar 

  12. Brachtel EF, Rusby JE, Michaelson JS, Chen LL, Muzikansky A, Smith BL, Koerner FC (2009) Occult nipple involvement in breast cancer: clinicopathologic findings in 316 consecutive mastectomy specimens. J Clin Oncol 27(30):4948–4954

    Article  PubMed  Google Scholar 

  13. Crowe JP, Patrick RJ, Yetman RJ, Djohan R (2008) Nipple-sparing mastectomy update: one hundred forty-nine procedures and clinical outcomes. Arch Surg 143(11):1106–1110 discussion 1110

    Article  PubMed  Google Scholar 

  14. Laronga C, Kemp B, Johnston D, Robb GL, Singletary SE (1999) The incidence of occult nipple-areola complex involvement in breast cancer patients receiving a skin-sparing mastectomy. Ann Surg Oncol 6(6):609–613

    Article  CAS  PubMed  Google Scholar 

  15. Luttges J, Kalbfleisch H, Prinz P (1987) Nipple involvement and multicentricity in breast cancer. A study on whole organ sections. J Cancer Res Clin Oncol 113(5):481–487

    Article  CAS  PubMed  Google Scholar 

  16. Morimoto T, Komaki K, Inui K, Umemoto A, Yamamoto H, Harada K, Inoue K (1985) Involvement of nipple and areola in early breast cancer. Cancer 55(10):2459–2463

    Article  CAS  PubMed  Google Scholar 

  17. Petit JY, Veronesi U, Orecchia R, Rey P, Martella S, Didier F, Viale G, Veronesi P, Luini A, Galimberti V et al (2009) Nipple sparing mastectomy with nipple areola intraoperative radiotherapy: one thousand and one cases of a five years experience at the European institute of oncology of Milan (EIO). Breast Cancer Res Treat 117(2):333–338

    Article  CAS  PubMed  Google Scholar 

  18. Rusby JE, Brachtel EF, Othus M, Michaelson JS, Koerner FC, Smith BL (2008) Development and validation of a model predictive of occult nipple involvement in women undergoing mastectomy. Br J Surg 95(11):1356–1361

    Article  CAS  PubMed  Google Scholar 

  19. Simmons RM, Brennan M, Christos P, King V, Osborne M (2002) Analysis of nipple/areolar involvement with mastectomy: can the areola be preserved? Ann Surg Oncol 9(2):165–168

    Article  PubMed  Google Scholar 

  20. Spear SL, Willey SC, Feldman ED, Cocilovo C, Sidawy M, Al-Attar A, Hannan C, Seiboth L, Nahabedian MY (2011) Nipple-sparing mastectomy for prophylactic and therapeutic indications. Plast Reconstr Surg 128(5):1005–1014

    Article  CAS  PubMed  Google Scholar 

  21. Vlajcic Z, Zic R, Stanec S, Lambasa S, Petrovecki M, Stanec Z (2005) Nipple-areola complex preservation: predictive factors of neoplastic nipple-areola complex invasion. Ann Plast Surg 55(3):240–244

    Article  CAS  PubMed  Google Scholar 

  22. Vyas JJ, Chinoy RF, Vaidya JS (1998) Prediction of nipple and areola involvement in breast cancer. Eur J Surg Oncol 24(1):15–16

    Article  CAS  PubMed  Google Scholar 

  23. Wang J, Xiao X, Wang J, Iqbal N, Baxter L, Skinner KA, Hicks DG, Hajdu SI, Tang P (2012) Predictors of nipple-areolar complex involvement by breast carcinoma: histopathologic analysis of 787 consecutive therapeutic mastectomy specimens. Ann Surg Oncol 19(4):1174–1180

    Article  PubMed  Google Scholar 

  24. Wertheim U, Ozzello L (1980) Neoplastic involvement of nipple and skin flap in carcinoma of the breast. Am J Surg Pathol 4(6):543–549

    Article  CAS  PubMed  Google Scholar 

  25. Wijayanayagam A, Kumar AS, Foster RD, Esserman LJ (2008) Optimizing the total skin-sparing mastectomy. Arch Surg 143(1):38–45

    Article  PubMed  Google Scholar 

  26. Burdge EC, Yuen J, Hardee M, Gadgil PV, Das C, Henry-Tillman R, Ochoa D, Korourian S, Suzanne Klimberg V (2013) Nipple skin-sparing mastectomy is feasible for advanced disease. Ann Surg Oncol 20(10):3294–3302

    Article  PubMed  Google Scholar 

  27. Coopey SB, Smith BL (2015) The nipple is just another margin. Ann Surg Oncol 22(12):3764–3766

    Article  PubMed  Google Scholar 

  28. Sisco M, Du H, Warner JP, Howard MA, Winchester DP, Yao K (2012) Have we expanded the equitable delivery of postmastectomy breast reconstruction in the new millennium? Evidence from the national cancer data base. J Am Coll Surg 215(5):658–666 discussion 666

    Article  PubMed  Google Scholar 

  29. Facility oncology registry data standards (2016) American College of Surgeons Commission on Cancer, Chicago

  30. Allison P (2005) Imputation of categorical variables with PROC MI. In: SUGI 30 Proceedings, vol. paper 113–30, Philadelphia

  31. National comprehensive cancer network clinical practice guidelines in oncology: BREAST cancer (Version 2016.1)

  32. Nattinger AB, Gottlieb MS, Veum J, Yahnke D, Goodwin JS (1992) Geographic variation in the use of breast-conserving treatment for breast cancer. N Engl J Med 326(17):1102–1107

    Article  CAS  PubMed  Google Scholar 

Download references

Author contributions

Sisco: Conceptualization, methodology, original draft, Kyrillos: Formal analysis, data curation, original draft, Lapin: Methodology, software, validation, formal analysis, resources, data curation, review and editing, visualization, Wang: Methodology, software, validation, formal analysis, resources, data curation, review and editing, visualization, Yao: Conceptualization, methodology, review and editing.

Funding

No external funding.

Author information

Authors and Affiliations

  1. Division of Plastic Surgery, NorthShore University HealthSystem, Northbrook, IL, 60062, USA

    Mark Sisco

  2. Division of Surgical Oncology, NorthShore University HealthSystem, Evanston, IL, 60201, USA

    Alexandra M. Kyrillos & Katharine A. Yao

  3. Center for Biomedical Research Informatics, NorthShore University HealthSystem, Evanston, IL, 60201, USA

    Brittany R. Lapin & Chihsiung E. Wang

Authors
  1. Mark Sisco
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Alexandra M. Kyrillos
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Brittany R. Lapin
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Chihsiung E. Wang
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Katharine A. Yao
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Mark Sisco.

Ethics declarations

Conflict of interest

The authors have no conflicts of interest to report.

Additional information

The data used in this study are derived from a de-identified National Cancer Data Base file. The American Cancer Society and American College of Surgeons Commission on Cancer have not verified and are neither responsible for the analytic or statistical methodology employed, nor the conclusions drawn by these investigators from the data.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Sisco, M., Kyrillos, A.M., Lapin, B.R. et al. Trends and variation in the use of nipple-sparing mastectomy for breast cancer in the United States. Breast Cancer Res Treat 160, 111–120 (2016). https://doi.org/10.1007/s10549-016-3975-9

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10549-016-3975-9

Keywords

Search

Navigation