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Health-related Quality of Life and Patient Satisfaction After Nipple-Sparing Mastectomy and Breast Reconstruction: Results from a Prospective Cohort of 300 Patients with Long-Term Follow-Up
Pathik Aravind, Ricardo J. Bello, MD,MPH, Mohamed Sebai, M.B.B.S, Eric L. Wan, BS, Charalampos Siotos, MD, Jeff W. Aston, BS, Sethly Davis, David Cui, Julie Lee, Michele A. Manahan, MD, Justin M. Sacks, MD,MBA, Carisa Cooney, MPH, Gedge Rosson, MD.
Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Background: Nipple-sparing mastectomy (NSM) is oncologically safe for select patients. However, patient-reported evidence on these benefits remains to be established in prospective, longitudinal studies. This study aimed to estimate differences in quality of life (QoL) and patient satisfaction among breast reconstruction patients comparing NSM to non-NSM mastectomies.
Methods: We prospectively followed patients undergoing breast reconstruction from 2010-2015 using the Breast-Q and RAND-36 preoperatively, after tissue expander placement, and 6 and 12 months after final reconstruction. We used simple and multiple linear regression to estimate associations between QoL in NSM compared to non-NSM types of mastectomy.
Results: Out of 300 patients, NSM was performed on 111 breasts in 66 patients, whereas 363 breasts in the remaining 234 patients underwent non-NSM. Out of the 66 NSM patients most were performed as staged reconstructions (81.8%), 13.6% were immediate and 4.5% were delayed reconstructions. Thirty-nine NSMs were followed with implant-based reconstruction (59.09%), 22 with abdominally-based autologous flap reconstructions (33.33%), and 5 with pure fat grafting (7.58%). At long-term follow-up, median Satisfaction with Breasts for NSM patients (64.5 points, inter-quartile range [IQR]: 50-75.5) was not significantly different compared to Non-NSM types of mastectomy (65, IQR: 53-78, p=0.525). In multivariable adjusted analysis, mean change in Satisfaction with Breasts was 5.96 points lower among NSM patients (95% confidence interval [CI]: -2.42 to 14.35 points lower, p=0.163). NSM was not associated with benefits in Psychosocial Wellbeing, Sexual Wellbeing, Physical Wellbeing: Chest, Physical Wellbeing: Abdomen, Summary Physical Health, or Summary Mental Health (Table 1).
Conclusions: There have been studies that provide evidence regarding the benefits of NSM. However, based on QOL related outcomes our study does not show NSM to be superior to other types of mastectomy. This is possibly due to patient selection and alternatives available at our institution, such as nipple reconstruction and tattooing. We believe that similar studies should be conducted in different population groups to better estimate the consistency of these findings. Though NSM has proven to be beneficial to patients as per the existing literature, it will be useful to improve metrics to evaluate NSM effectiveness and to identify what exactly these benefits are.

Table 1: Quality of Life, Patient Satisfaction, and Clinical Outcomes in a Cohort of 300 Breast Reco
Unadjusted AnalysisAdjusted Analysis
Continuous OutcomesGroupMedian (IQR)p-valueMean difference*95% CIP-value
Satisfaction with BreastsNSM64.5 (50-75.5)0.525-5.96-14.35 to 2.420.163
Non-NSM65 (53-78)
Psychosocial WellbeingNSM76 (56.5-92)0.507-1.60-8.64 to 5.440.655
Non-NSM79 (60-100)
Sexual WellbeingNSM60 (47-81.5)0.1650.61-7.81 to 9.040.886
Non-NSM54 (44-67)
Physical Wellbeing of ChestNSM77 (68-91)0.600-2.77-7.76 to 2.220.276
Non-NSM81 (66-91)
Physical Wellbeing of AbdomenNSM89 (70-100)0.434-1.46-12.69 to 9.760.796
Non-NSM89 (70-100)
RAND-36 Physical Health Summary ScoreNSM99.8 (72.5-96.3)0.5524.57-4.69 to 13.830.332
Non-NSM88.8 (68.8-95)
RAND-36 Mental Health Summary ScoreNSM84.4 (68.5-87.5)0.311-0.45-9 to 8.100.917
Non-NSM82 (71-86.5)
Categorical OutcomesGroupN (%)p-valueOdds Ratio*95% CIP-value
Postoperative complications - immediate**NSM18 (27.27%)0.0261.311.03 to 1.680.027
Non-NSM36 (15.38%)
Postoperative complications - delayed**NSM18 (27.27%)0.4581.090.9 to 1.340.361
Non-NSM75 (32.05%)

*Mean differences and Odds Ratios use non-NSM as baseline, hence positive values favor NSM and negative values favor non-NSM.
**Postoperative complications are presented as those recorded after mastectomy and immediate breast reconstruction (or after tissue expander in staged) and those recorded after delayed reconstruction (or final reconstruction in staged).

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