Decision-Making, Reconstructive Outcomes and Patient Satisfaction in Young BRCA+ Patients Undergoing Prophylactic Nipple-Sparing Mastectomy
Ara A. Salibian, MD, Jordan D. Frey, MD, Jonathan M. Bekisz, MD, MsC, Brooke Miller, NP, Mihye Choi, MD, Nolan S. Karp, MD.
NYU Langone Health, New York, NY, USA.
Background: Prophylactic nipple-sparing mastectomies (NSMs) in young “previvors” with high-risk genetic mutations are rising dramatically with increasing awareness of cancer predispositions and genetic testing. However, there is a paucity of data on patient management, appropriate timing of diagnostic and interventional therapies, and surgical and patient-reported outcomes.
Methods: A retrospective review of BRCA+ patients under the of age 30 undergoing prophylactic NSM from 2006-2018 at a single institution was performed. Demographics, indications, referral trends, operative characteristics and reconstructive outcomes were analyzed. A survey was developed to query patient decision-making, utility of available patient resources, decisions for undergoing surgery and preoperative patient comprehension. Patients also completed BREAST-Q surveys to evaluate satisfaction and quality of life.
Results: Twenty-two patients (44 breasts) ages 23 to 29 (mean 27) underwent prophylactic NSM for BRCA1 (68.2%) and BRCA2 (31.8%) diagnoses. Average age of genetic diagnosis was 22.9 after which patients waited, on average, 4.1 years to surgery. Most patients were referred by breast surgeons (45.5%), though 22.7% presented initially to plastic surgeons. Eighty-two percent of patients had a first-degree relative with BRCA or breast cancer diagnoses.
All patients underwent immediate reconstructions with two-stage tissue expanders (77.3%), immediate implants (18.2%), or abdominal perforator flaps (4.5%). There were no cases of complete nipple or major mastectomy flap necrosis. Four breasts (9.1%) had partial nipple necrosis resolved with wound care (Table 1). There were no cancer occurrences within a mean follow-up of 40 months.
Eleven patients completed surveys at an average of 28.8 months postoperatively. Most patients (63.6%) cited family advice and personal decisions (fear of getting cancer; peace of mind) as the most important reasons for genetic testing, and personal decision (63.6%) for mastectomy. 81.8% cited recommendations of their plastic surgeon as the most important influence in reconstructive modality. 81.8% of patients would undergo mastectomy and 90.9% reconstruction at the same age. 63.6% of patients felt they completely understood risks and benefits of NSM and 72.7% of reconstruction. Patients reported high BREAST-Q scores for Satisfaction with Breasts (74.6), Satisfaction with Information (79.3), Physical Well-Being (82.9), Psychosocial Well-Being (79.9) and Sexual Well-Being (83).
Conclusions: Young adults with high-risk mutations undergoing prophylactic NSM and reconstruction have low rates of complications and high satisfaction and quality of life. Decisions to undergo testing and surgery are highly personal, though health-care professionals are influential in treatment choices. Continued development of educational resources is needed to optimize shared decision-making in the reconstructive process.
| Table 1. Patient Demographics, Operative Characteristics and Outcomes in Prophylactic Nipple-Sparing Mastectomy in High-Risk Patients Less than 30 Years of Age | |
| Value (%) | |
| Patient Demographics | |
| Age (years)* | 27.0 ± 0.3 |
| BMI (kg/m2)* | 23.6 ± 0.4 |
| Diabetes Mellitus | 0 |
| Tobacco Use | |
| Active | 1 (4.5%) |
| Former | 0 |
| Family history of breast cancer** | 18 (81.8%) |
| Referring specialty | |
| Breast Surgery | 10 (45.5%) |
| Genetics Counselor | 2 (9.1%) |
| Gynecology | 1 (4.5%) |
| Plastic Surgery | 5 (22.7%) |
| Oncology | 4 (18.2%) |
| Operative Characteristics | |
| Average Mastectomy Weight* | 442.2± 22.3 |
| Reconstruction Timing | |
| Immediate | 44 (100%) |
| Delayed | 0 |
| Incision Type | |
| Inframammary | 40 (90.9%) |
| Lateral Radial | 4 (9.1%) |
| Reconstructive Technique | |
| Tissue Expander | 34 (77.3%) |
| Immediate Implant | 8 (18.2) |
| DIEP Flap | 2 (4.5%) |
| Implant Position | |
| Dual-Plane | 26 (61.9%) |
| Total Submuscular | 16 (38.1%) |
| Implant Type | |
| Smooth Round Implant | 36 (94.7%) |
| Textured Anatomic Implant | 2 (5.3%) |
| Implant Size* | 495.6 ± 19.8 |
| Outcomes | |
| Reconstructive Complications | |
| Complete Nipple Necrosis | 0 |
| Partial Nipple Necrosis | 4 (9.1%) |
| Major Mastectomy Flap Necrosis | 0 |
| Minor Mastectomy Flap Necrosis | 0 |
| Major Infection (Intavenous Antibiotics) | 0 |
| Minor Infection (Oral Antibiotics) | 1 (2.3%) |
| Wound Dehiscence | 0 |
| Seroma | 0 |
| Hematoma | 1 (2.3%) |
| Flap Compromise (Return to OR) | 0 |
| Flap Loss | 0 |
| Follow-Up (months)* | 39.9 ± 4.0 |
| BMI, body-mass index; DIEP, deep inferior epigastric artery perforator; ADM, acellular dermal matrix; OR, operating room. *Mean ± standard error of the mean; **First degree relative with breast cancer | |
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