Let me begin by thanking Dr. Jensen for responding to our article on nipple-sparing mastectomy. Also, let me congratulate him and his colleagues for being ahead of the curve and writing about this in an editorial that was published in this same Journal in February of 2002. Along the same lines, my apologies to him and some of his other referenced publications that pertain to this important, controversial, and emerging subject.
My fellow authors and I attempted to be comprehensive but also selective in our references and unintentionally excluded some that might have been worthy of mentioning.
That being said, the easiest answer to the question regarding what is the best evidence for the safety of nipple-sparing mastectomy is “not one reference, but the weight of the evidence,” from multiple centers and multiple studies.
The weight of the evidence from the references in our article and the additional ones cited by Dr. Jensen is that nipple-sparing mastectomy in properly selected and tested patients is safe and yields survival results comparable to those of other similar stage patients.
The algorithm that we put forth was not intended to be a hard rule barring attempting nipple-salvage in women who do not fit. On the contrary, it was an invitation to be optimistic about attempting nipple-sparing in women who do fit the criteria. We frequently will stretch the criteria and attempt to “conserve” the nipple in women with nonideal clinical presentations, but the criteria that we propose do tend to select the better candidates.
Dr. Jensen's original editorial was optimistic about nipple sparing in patients with ductal carcinoma in situ which, it turns out, is a negative predictor for being able to save the nipple. This ironic finding does not preclude us from trying, but these patients are more likely to have disease near their nipple, albeit not invasive.
We recommend avoiding the excessively large or ptotic breast, but there are ways to manage some of these patients and save their nipples, depending on the patient's motivation and the surgical team's ingenuity and skill. The important message here is that thoughtful selection and screening using some criteria based on the available literature and wide experience will allow surgeons who are so motivated to offer nipple-sparing mastectomy to women at high risk for or having breast cancer.
Our criteria may be somewhat more conservative than Dr. Jensen's, but it has been 7 years since his editorial, and most surgeons in most centers have been reluctant to follow his advice.
Our intent was to try to move this process along and do our best to advise our colleagues on a prudent and safe path in terms of both oncology and anatomy. We do not want to hear about a large number of local recurrences, even if it turns out that they do not tend to impact survival in many or most cases. If there are a large number of complications, disappointments, or local recurrences, it will set this concept back another decade or worse.
Finally, let me congratulate Dr. Jensen for being ahead of the curve on this. As he has seen, if you are too far ahead of the curve, it takes a long time for others to catch up.
Scott L. Spear, M.D.
Department of Plastic Surgery
Georgetown University Hospital, 1-PHC
3800 Reservoir Road, NW
Washington, D.C. 20007-2113
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