By Richard E. Fine, MD, FACS
Actress Angelina Jolie just announced that she underwent a preventive double mastectomy after learning that she was genetically predisposed to cancer. Her disclosure was a powerful show of solidarity with the more than 100,000 American women who undergo breast removal surgery each year.
But Jolie’s story, while inspirational, is different from most women’s. She benefited from a relatively uncommon nipple-sparing mastectomy (NSM), a procedure that removes the breast tissue while preserving the breast skin and nipple. With NSM, after reconstructive surgery, breasts are left looking mostly unchanged.
Such procedures are rare — but they don’t have to be. Recent advances in medical technology have made NSM and skin-sparing mastectomies (SSM) much safer and easier to perform. And yet, too few breast cancer patients know about these options. Bridging this knowledge gap is the only way to ensure that more women aren’t needlessly disfigured.
Roughly 260,000 people are diagnosed with breast cancer each year in the United States. For many of them, the news of their illness is followed by a seemingly unthinkable treatment recommendation: a mastectomy.
The most common form of this procedure, known as a simple or total mastectomy, removes the entire breast, including much of the skin and the nipple. Even if it eliminates the cancer, the disfiguring effects of the surgery can bring overwhelming psychological pain, especially for younger women. As a breast surgeon, I have witnessed the devastating emotional consequences of this procedure all too often.
It isn’t just diagnosed cancer patients who must deal with the distressing aftermath of a simple mastectomy. Like Jolie, many healthy women with a heightened genetic risk of developing breast cancer choose to have some form of preventive breast removal.
From a medical standpoint, there’s no reason that simple mastectomies should be the norm. Both NSM and SSM are minimally invasive procedures that, in the right patients, are as effective as simple mastectomies and carry considerable cosmetic and emotional benefits. With NSM specifically, not only can breasts look the same after reconstruction, according to many patients, they may look better.
And yet, NSM currently accounts for about 10 percent of the mastectomies performed. That so many women are being denied the chance to preserve most of the skin and the nipple and therefore a more natural appearance of their breasts is disheartening.
The problem is one of education. Women are often told by their doctors that NSM and SSM are difficult to perform and bring a higher risk of cancer recurrence. In fact, a 2011 study in the Journal of the American College of Surgeons found that SSM and NSM appear to be oncologically safe and did not increase the risk of cancer recurrence. A study in Plastic & Reconstructive Surgery in 2011 examined the results of NSM over 20 years and came to a similar conclusion.
As for the supposed difficulty of the surgery, that too is a misconception. I can personally attest that new technologies like the Eigr illuminated breast retractor system have made it possible to perform NSM and SSM more easily, more quickly, and with fewer complications. Such advances should help these procedures become more widely adopted.
Unfortunately, many physicians have remained in the dark about recent improvements in breast surgery. Recognizing the need to educate surgeons about NSM, the American Society of Breast Surgeons has launched the Nipple-Sparing Mastectomy Registry to track the long-term results of those patients who undergo this procedure. But this is only a small step in the right direction.
Addressing this knowledge crisis will require women to play an active role by learning about their treatment options, seeking out informed physicians, and asking the right questions. To this end, there are a variety of valuable resources, including organizations like the American Cancer Society and websites like www.
Angelina Jolie’s remarkable story should bring hope to breast cancer patients and those at risk of developing the illness. Procedures like Jolie’s are available to all women. The challenge now is to ensure that surgeons are trained – and patients are educated – in less-invasive techniques that vastly reduce the psychological and emotional effects of this life-saving surgery.
Dr. Richard E. Fine is a breast surgeon at The West Clinic Comprehensive Breast Center and Associate Clinical Professor, Department of Surgery, University of Tennessee, Chattanooga Division. He is a Past President of the American Society of Breast Surgeons.
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