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Nipple-Sparing Mastectomy Update—Invited Critique

Nipple-Sparing Mastectomy Update—Invited Critique When considering NSM, the most important factor is the oncologic safety of the procedure. There are populations of patients, specifically those undergoing prophylactic mastectomy, where NSM is a good choice. However, in patients with breast cancer, the oncologic safety becomes paramount. The Crowe et al article is a triumph in number of cases and developed technique, but it provides less convincing evidence that NSM is oncologically sound. To know if this is a safe cancer operation, we must determine if the risk of local recurrence is increased by leaving the NAC. Of the 43 patients with invasive breast cancer reported, 4 developed recurrence, a 9% recurrence rate. The recurrence rate after mastectomy is 3% to 6%, and for lumpectomy and radiation therapy, it is 6% to 8%. One must question whether NSM results in equivalent local control compared with standard therapies. While the recurrences reported herein are not at the NAC, the recurrence rate is relatively high in a breast cancer population selected for low-risk disease. Crowe et al report strict selection criteria that would predict a low risk for local recurrence; however, the evidence establishing those selection criteria is not described nor is the expected local recurrence after standard mastectomy in the same population. In counseling patients regarding risks and benefits, the Crowe et al article provides information regarding the risk of NSM but provides no information of the benefits, primarily an expected improvement in patient satisfaction. We make the assumption that patient satisfaction is high but have no accurate measure. While we applaud Crowe et al on this endeavor with the second largest number of patients in the literature, we ask them to assure us that presumed benefits are real and that NSM is truly oncologically safe. Correspondence: Dr Jacobs, Department of Surgery, Johns Hopkins University, 600 N Wolfe St, Osler 625, Baltimore, MD 21287 (ljacob14@jhmi.edu). Author Contributions:Study concept and design: Jacobs and Voltura. Drafting of the manuscript: Jacobs and Voltura. Critical revision of the manuscript for important intellectual content: Jacobs. Administrative, technical, and material support: Jacobs and Voltura. Study supervision: Jacobs. Financial Disclosure: None reported. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Surgery American Medical Association

Nipple-Sparing Mastectomy Update—Invited Critique

Archives of Surgery , Volume 143 (11) – Nov 17, 2008

Nipple-Sparing Mastectomy Update—Invited Critique

Abstract

When considering NSM, the most important factor is the oncologic safety of the procedure. There are populations of patients, specifically those undergoing prophylactic mastectomy, where NSM is a good choice. However, in patients with breast cancer, the oncologic safety becomes paramount. The Crowe et al article is a triumph in number of cases and developed technique, but it provides less convincing evidence that NSM is oncologically sound. To know if this is a safe cancer operation, we must...
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Publisher
American Medical Association
Copyright
Copyright © 2008 American Medical Association. All Rights Reserved.
ISSN
0004-0010
eISSN
1538-3644
DOI
10.1001/archsurg.143.11.1110
Publisher site
See Article on Publisher Site

Abstract

When considering NSM, the most important factor is the oncologic safety of the procedure. There are populations of patients, specifically those undergoing prophylactic mastectomy, where NSM is a good choice. However, in patients with breast cancer, the oncologic safety becomes paramount. The Crowe et al article is a triumph in number of cases and developed technique, but it provides less convincing evidence that NSM is oncologically sound. To know if this is a safe cancer operation, we must determine if the risk of local recurrence is increased by leaving the NAC. Of the 43 patients with invasive breast cancer reported, 4 developed recurrence, a 9% recurrence rate. The recurrence rate after mastectomy is 3% to 6%, and for lumpectomy and radiation therapy, it is 6% to 8%. One must question whether NSM results in equivalent local control compared with standard therapies. While the recurrences reported herein are not at the NAC, the recurrence rate is relatively high in a breast cancer population selected for low-risk disease. Crowe et al report strict selection criteria that would predict a low risk for local recurrence; however, the evidence establishing those selection criteria is not described nor is the expected local recurrence after standard mastectomy in the same population. In counseling patients regarding risks and benefits, the Crowe et al article provides information regarding the risk of NSM but provides no information of the benefits, primarily an expected improvement in patient satisfaction. We make the assumption that patient satisfaction is high but have no accurate measure. While we applaud Crowe et al on this endeavor with the second largest number of patients in the literature, we ask them to assure us that presumed benefits are real and that NSM is truly oncologically safe. Correspondence: Dr Jacobs, Department of Surgery, Johns Hopkins University, 600 N Wolfe St, Osler 625, Baltimore, MD 21287 (ljacob14@jhmi.edu). Author Contributions:Study concept and design: Jacobs and Voltura. Drafting of the manuscript: Jacobs and Voltura. Critical revision of the manuscript for important intellectual content: Jacobs. Administrative, technical, and material support: Jacobs and Voltura. Study supervision: Jacobs. Financial Disclosure: None reported.

Journal

Archives of SurgeryAmerican Medical Association

Published: Nov 17, 2008

Keywords: nipple-sparing mastectomy

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