August 27th, 2009 by RamonaBatesMD in Better Health Network
No Comments »
Two nice articles in the June edition of the Journal of Plastic and Reconstructive Surgery. Full references are given for both below.
There are many techniques used for nipple reconstruction which should tell you that none is perfect. One of the main issues is loss of nipple projection over time. So if it is safe to spare the nipple when doing a mastectomy so no nipple reconstruction is needed – perfect!
The first article below looks at when it can be safely spared in prophylactic mastectomy (risk-reduction mastectomy) and therapeutic mastectomy clinical scenarios. Spear and colleagues did a literature review and came to the following conclusion:
It is clear from a review of the literature of the past 15 years that the subject of nipple-sparing mastectomy is complex and evolving. The subject is properly divided into two parts: risk prevention and therapeutic mastectomy.
There now seems little doubt that nipple-sparing mastectomy is an oncologically safe approach to prophylactic mastectomy. For that purpose, proper patient selection and technique remain open questions. ……….
Nipple-sparing mastectomy at the time of therapeutic mastectomy remains more controversial. There is developing consensus by those interested in nipple-sparing mastectomy as a possibility with therapeutic mastectomy that it is best suited for women who meet certain criteria. …….
The collective data suggest that, using the above below criteria, the risk of occult tumor in the nipple should be 5 to 15 percent; that frozen section of the base of the nipple will identify many if not most of those occult tumors; and that the risk of occult tumor still being present in patients screened as above with frozen section-negative findings is as low as 4 percent.
The tumor criteria listed include:
- The tumor should be 3 cm in diameter or less
- The tumor should be 2 cm away from center of the nipple
- Clinically negative axillae or sentinel node negative
- No skin involvement, and no inflammatory breast cancer.
- If possible, they should undergo preoperative magnetic resonance imaging of the breast to further exclude nipple involvement.
When the nipple can be spared then there is no need for nipple reconstruction. When it can’t be, then the nipple sharing technique can be useful. As with the above, the cancer risk is addressed:
Fears of cancer in the transplanted nipple and concerns for surveillance are thus far unfounded. This occurrence has never been described in the literature. Furthermore, as more liberal use of nipple-sparing mastectomy occurs, a large cohort of patients with retained nipples will be able to be followed over time to see whether we even need to be concerned. For now, simple self-examination as performed by these patients is appropriate.
The article gives a good description of two different ways to perform the nipple sharing depending on the shape of the donor nipple.
Both articles are worth your time to read.
REFERENCES
Nipple-Sparing Mastectomy; Plast & Recontr Surg 123(6):1665-1673, June 2009; Spear, Scott L.; Hannan, Catherine M.; Willey, Shawna C.; Cocilovo, Costanza
Unilateral Nipple Reconstruction with Nipple Sharing: Time for a Second Look; Plast & Reconstr Surg 123(6):1648-1653, June 2009; Zenn, Michael R.; Garofalo, Jo Ann
Related Posts
Breast Reconstruction – Part I
Breast Reconstruction – Part II
Integrating Radiation Therapy & Breast Reconstruction
*This blog post was originally published at Suture for a Living*
October 19th, 2008 by Dr. Val Jones in Expert Interviews
No Comments »
Even though I live in DC it was my first visit to the Department of State. I was surprised by the level of security (I passed through 2 metal detectors to get to the conference) and the multitude of languages spoken by the attendees. Many were wearing headphones, which were connected to a translator service. The lectures were rapidly translated into the various languages of the audience members (the way it would for the United Nations meetings), though I enjoyed the ability to listen directly to the speakers in my native tongue.
I was able to interview a keynote speaker, Joe Harford, Ph.D., the Director of the Office of International Affairs, of the National Cancer Institute. Here’s what he had to say:
Dr. Val: Why is the risk of breast cancer (in the US) greater now than in previous generations?
Dr. Harford: The main cause of the increase is related to changes in reproductive patterns within the population as a whole. Women who have fewer children (and later in life) tend to have higher risk of breast cancer. This is associated with hormones – the breast is a hormonally responsive organ and breast cells that convert to tumor cells also have hormone receptivity. Pregnancy and breast feeding are protective for breast tissue. Women can check out their risk for developing breast cancer by filling out this
short, online assessment tool at the NCI.
Read more »
April 17th, 2008 by Dr. Val Jones in News
3 Comments »
My friend (and occasional guest blogger here at the Voice of Reason) Dr. Avrum Bluming just co-authored an eye-opening exposé of breast cancer risk factors and how they’re overblown for media purposes. This article was published in the Los Angeles Times today. Here is an excerpt:
We now have a fat file folder of all the studies we could find that have reported an association between some purported risk factor and breast cancer. Of these, the ones that got the most attention were three Women’s Health Initiative reports. In 2002, investigators found an increased relative risk of 26% from using combined estrogen and progesterone; in 2003, it was 24%; and in 2004, the relative risk from using estrogen alone was minus 23% (suggesting it was protective against breast cancer).
To put those findings in perspective, consider these published studies showing the increased relative risk of breast cancer from:
* eating fish: 14%
* eating a quarter of a grapefruit a day: 30%
* gaining more than 33 pounds in pregnancy: 61%
* being a Finnish flight attendant: 87%
* being a Dutch survivor of childhood famine: 201%
* using antibiotics: 207%
* having a diagnostic chest X-ray: 219%
* being an Icelandic flight attendant: 410%
* using an electric blanket: 630% (but only if you are a black woman who used it for more than 10 years but less than six months in a given year).
Why was there no call for Icelandic flight attendants to quit (or transfer to Lufthansa), for black women to use electric blankets for more than six months a year but only for nine years, for labeling antibiotics as carcinogens? Because these findings, which were improbable to begin with, were never replicated. In contrast, the increased relative risk of lung cancer from smoking is consistently between 2,000% and 3,000%. That’s a finding that means something.
Unfortunately, good news doesn’t travel as fast as fear does. In 2006, the Women’s Health Initiative investigators reanalyzed their data and found that the risk of breast cancer among women who had been randomly assigned to take hormone replacement therapy was no longer significant. Women assigned to take a placebo but who had used hormone replacement therapy in the past actually had a lower rate of breast cancer than women who had never taken hormones.
This reassuring but non-scary news did not make headlines…
To read the rest of the fascinating article, click here.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
March 6th, 2008 by Dr. Val Jones in Expert Interviews
3 Comments »
I must admit that I was a bit skeptical of the conclusions drawn by the media about the latest analysis of the Women’s Health Initiative (WHI) data. The WHI study has generated many different spin-off articles about hormone replacement therapy and its potential link to breast cancer. This latest review suggests that the increased risk for cancer persists up to five years after stopping HRT treatment for menopausal symptoms. I asked Revolution Health expert and past president of the American College of Obstetricians and Gynecologists, Dr. Vivian Dickerson, to help us put this new article into context.
Dr. Val: What does this new study contribute to our understanding of the risks of HRT?
Dr. Dickerson: First of all the women in this study were not on estrogen alone (the usual treatment for women who have had hysterectomies). Their HRT consisted of a combination of Premarin (estrogen) and Provera (progesterone). The original study indicated a slightly higher (barely statistically significant) increased risk for cardiovascular disease (CVD) and a statistically significant increased risk in breast cancer (but relative risks were less than 1.5 for both, which is very small).
Now all this new analysis tells me is that the CVD risk appears to extinguish or become negligible after three years though there is still an increase in breast cancers (compared to placebo) but the difference was not statistically significant. This is interesting in that it does add some plausibility to the claim that the reason breast cancer rates declined so significantly in the year(s) after WHI is because of all the women who quit taking HRT. It doesn’t prove anything, but just more grist for the mill. (Unfortunately I don’t see sub-group analyses of the women who chose to continue HRT after the end of WHI and those who quit from the treatment group.)
The study authors used some fancy math to demonstrate that there was a statistically significant increase in all-cause mortality (including breast cancer) for the women in the HRT group. Since the relative risk is so low, all they can say is that there is no reason to use HRT as a protective or primary preventive measure against heart disease, which we’ve known for many years now.
Dr. Val: Would you change your HRT recommendations based on this new analysis of the WHI data?
Dr. Dickerson: I wouldn’t change a thing that I am doing or counseling. These data are weak and the differences are not robust in any parameter.
***
So there you have it, ladies. No need for heightened alarm based on this analysis of the WHI data, especially if you have never been on the Premarin/Provera cocktail. It would be really helpful to compare breast cancer rates in women who stopped HRT versus those who continued it after the initial WHI data were released. Let’s keep our fingers crossed that this subgroup analysis is next up for publication.
Addendum: My friend and HRT expert, Dr. Avrum Bluming, kindly wrote me an email to further underscore the dubious nature of this study’s findings. Here’s what he said:
“The paper reads more like a lawyer’s presentation then a scientific article (i.e. it makes points followed by the disclaimer that the findings represented are not statistically significant—but the points have been registered). Instead of concluding that the very small increased risk of harm associated with estrogen and progesterone combination therapy (reported in the original studies, which were of questionable significance in the first place) are not found 2+ years after HRT was stopped, they find new risks (lung cancer) to allow them to conclude that administration of HRT results in delayed increased risks.”This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
October 8th, 2007 by Dr. Val Jones in Health Tips
4 Comments »
You’d think that all my friends were participating in breast cancer awareness month – first the abnormal mammogram scare, now a new email from a young, worried friend: “I found a lump in my breast. What should I do?”
My friend is 28 years old, with no family history of breast cancer. However, I take all lumps seriously because my husband’s sister was diagnosed in her early 30’s, after complaining of some hip pain followed by an x-ray which revealed diffuse metastases. Nonetheless, it bears repeating that a breast lump in a woman in her 20’s is highly unlikely to be cancer. For those of you out there who have found a lump in your breast, here are the statistics:
- An estimated 90% of breast lumps are benign (and that includes lumps in significantly older women).
- The number one risk factor for breast cancer is age. The risk of a woman in her 30’s having breast cancer is <0.43%. The National Cancer Institute doesn’t have per cent risks for women in their 20’s but I’m sure it’s even lower.
- Fibrocystic breast tissue occurs in up to 60% of all women, and has a lumpy texture.
- Breast cysts are fairly common, up to 7% of western females have a breast cyst at some point in their lifetimes.
- Breast lumps often occur in response to normal hormonal fluctuations in the menstrual cycle
So if you find a breast lump, you should have it evaluated, but please keep in mind that there’s a 60% chance that it’s due to harmless fibrocystic changes, and (if you’re in your 30’s) a 0.43% chance that you’ll develop cancer. Indeed, most lumps are benign at all ages.
The next step in a lump evaluation is to have an ultrasound and if you’re over 35 to also have a mammogram, and then if the clinical images warrant it, a biopsy to confirm the contents of the lump. Also keep in mind that once you’ve had a biopsy, you can expect some scarring which could be read as “abnormal” in future mammograms. So don’t be surprised if you get an abnormal mammogram later on after the biopsy.
Breast cancer awareness is very important and can save lives, but on the flip side it can also make us paranoid about our breasts. My advice would be to take any lumps seriously, but also know that it’s not cancer until proven so – and that most women have breasts with a somewhat lumpy texture, so if you don’t have any lumps, you’re technically in the minority.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
