A recent study compared two types of mastectomies: the conventional nipple-sparing mastectomy (NSM) and keyhole methods (using endoscopic or robotic approaches) [1] Conducted across five tertiary hospitals in Taiwan, the study involved 73 conventional NSM cases and 160 keyhole NSM of which 84 cases used endoscopic approach and 76 cases with robotic assistance. Here’s what it revealed about the pros and cons of these methods.
What Are Keyhole Surgeries?
Keyhole surgeries, also known as minimal access surgeries, involve making small incisions and using specialised long thin instruments e.g. a wand-like camera to assist with the procedures. These methods are common in abdominal and pelvic keyhole surgeries, where they have revolutionised care by reducing post-operative pain, recovery times and complications[2]. In breast surgery, however, keyhole approaches are still evolving and has not replaced the conventional NSM as the standard of care.
Study Findings: How Do These Approaches Compare?
The study revealed several key points[1]:
- Surgery Time and Recovery: All approaches had similar operating times and recovery periods. In skilled hands, keyhole methods could be faster.
- Wound Healing: Smaller scars (4 cm vs. 9 cm) and better healing were observed in keyhole surgeries, with fewer cases of delayed healing.
- Complications: All approaches had low complication rates, and overall safety was similar.
- Patient Satisfaction: Patients in all groups reported high satisfaction with their results, including psychosocial and physical well-being, for instance skin sensation, arm function and minimal or no chronic pain.
- Costs: Robotic surgeries were more expensive than conventional and endoscopic methods.
To date, conventional mastectomy remains the standard of care due to the following reasons:
- Easier Accessibility and Surgeon Expertise: Conventional mastectomy is widely accessible because it does not require specialised equipment like robotic and endoscopic systems, making it suitable for hospitals with limited resources. Most surgeons are already familiar and experienced in the conventional approach: ensuring reliable and consistent results.
- Comprehensive Cancer Removal for Complex Cases: The conventional approach offers direct access, visualisation and tactile appreciation of the surgical site, enhancing the surgeon’s ability to ensure complete cancer removal. This makes it particularly effective for complex cases, such as advanced or multifocal cancers, where extensive tissue removal is necessary to ensure oncologic safety.
- Simplified Reconstruction Options: The larger incision in conventional NSM allows easier access for various immediate breast reconstruction options, providing more surgical flexibility in terms of reconstructive options
- Proven Long-Term Outcomes: With a long-established track record, conventional mastectomy has demonstrated consistent effectiveness and safety in breast cancer treatment.
- Cost-Effectiveness and Lower Maintenance Costs: Conventional NSM costs less than robotic or endoscopic surgeries, as it avoids the additional and often high costs of advanced equipment. Hospitals also benefit from reduced maintenance expenses, further enhancing its cost-effectiveness.
- Versatility Across Patient Profiles: Conventional NSM is highly adaptable, making it suitable for a wide range of patients, including larger advanced cancers involving skin, the patient’s physical habitus or unique anatomical considerations. Unlike minimal access approaches, it has fewer technical constraints, ensuring broader eligibility.
Mastectomy Rates Around the World and in Singapore
Globally, mastectomy rates vary widely due to differences in healthcare practices, cultural attitudes, access to reconstructive surgery and alternative treatments like breast-conserving surgery (BCS) and radiotherapy.
For average-risk women in USA, overall mastectomy rates are 31% with a rising trend of double mastectomies of up to 49% in certain states[3][4]. Such a trend was not observed in Europe, as reported by an Italian study where mastectomy rates have remained stable at 34% with no increase in women opting for double mastectomies[5]. In Singapore – mastectomy rates have remained consistently high over the past two decades. A review over a 10-year period in a single institution from 2001 to 2010 reported mastectomy rates remained high throughout the period, varying between 43% and 59%[6]. Separately another review from another local institution reported 70% of patients treated during the same period underwent mastectomy with a low rate (1.25%) of double mastectomies[7].
Who Needs a Mastectomy?
Mastectomy is often necessary for women with large tumours or widespread cancer within the breast. However, advances in cancer screening and treatment have reduced the need for mastectomy in many cases. In Singapore, most breast cancers diagnosed today are small (under 2 cm)[8], making breast-conserving surgery (removing the tumour while preserving the breast) a welcoming option for most patients.
For larger cancers, modern therapies like pre-surgery treatments (neoadjuvant therapy) can shrink tumours, allowing many women to avoid mastectomy altogether[9][10]. On the other hand, genetic testing has led to greater awareness and a trend of more healthy but at-risk women considering double mastectomies as a preventive strategy to lower their cancer risk[11].
Special considerations for Scar Concealment in Conventional Mastectomies
Increasingly, surgeons have focused on concealing scars wherever possible during conventional mastectomies. Dr. Esther Chuwa from Solis Breast Care & Surgery emphasises, “Surgical scars are a necessity with any surgery: most patient are able to accept that. But by placing incisions in well-hidden areas like the skin folds beneath the breast, we can minimise its visibility while ensuring that oncologic safety is maintained. This approach contributes immensely to patients feeling more confident and hopeful during their recovery as visually, they are not constantly reminded of their diagnosis”
This approach ensures that oncologic principles, including adequate tumour removal, are not compromised while simultaneously addressing the patient’s aesthetic and emotional concerns. Considering these factors plays a significant role in enhancing the emotional well-being and overall recovery of breast cancer patients.
Looking Ahead
While keyhole surgeries offer smaller scars and potentially better wound healing, conventional mastectomy remains a trusted and effective choice for breast cancer surgery. As technology advances, keyhole approaches may gain momentum in replacing the conventional approach as the standard of care, but for now, the conventional approach continues to deliver excellent outcomes for most patients.
The future of breast surgery is bright, with ongoing research exploring new tools and techniques to improve care. Whether through minimal access or conventional methods, the goal remains the same: safe, effective, and personalised treatment for every patient.
Article contributed and reviewed by Dr Esther Chuwa, Senior Consultant and Breast Surgeon at Solis Breast Care & Surgery
References:
[1] Lai HW et al. Robotic Versus Conventional or Endoscopic-assisted Nipple-sparing Mastectomy and Immediate Prosthesis Breast Reconstruction in the Management of Breast Cancer: A Prospectively Designed Multicenter Trial Comparing Clinical Outcomes, Medical Cost, and Patient-reported Outcomes (RCENSM-P). Ann Surg. 2024 Jan 1;279(1):138-146.
[2] Velanovich V. Laparoscopic vs open surgery: A preliminary comparison of quality-of-life outcomes. Surg Endosc. 2000;14:16–21.
[3] Kummerow KL, Du LP, Penson DF, Shyr Y, Hooks MA Nationwide trends in mastectomy for early stage breast cancer. JAMA Surg. 2015;150(1):9-16.
[4] Steiner, C.A., Weiss, A.J., Barrett, M.L., Fingar, K.R. and Davis, P.H. (2016) Trends in Bilateral and Unilateral Mastectomies in Hospital Inpatient and Ambulatory Settings, 2005-2013. HCUP Statistical Brief #201. Agency for Healthcare Research and Quality.
[5] Fancellu A et al. Mastectomy patterns, but not rates, are changing in the treatment of early breast cancer. Experience of a single European institution on 2315 consecutive patients. Breast. 2018 Jun;39:1-7.
[6] Chan PM et al. Mastectomy rates remain high in Singapore and are not associated with poorer survival after adjusting for age. SpringerPlus 2015 Nov 10;4:685.
[7] Sim YR et al. Contralateral prophylactic mastectomy in an Asian population: a single institution review. Breast. 2014;23(1):56–62.
[8] Singapore Cancer Registry Annual Report 2022
[9] Golshan M et al. Impact of neoadjuvant therapy on eligibility for and frequency of breast conservation in stage II-III HER2-positive breast cancer: surgical results of CALGB 40601 (Alliance). Breast Cancer Res Treat 2016;160:297-304
[10] Golshan M et al. Impact of neoadjuvant chemotherapy in stage II-III triple negative breast cancer on eligibility for breast-conserving surgery and breast conservation rates: surgical results from CALGB 40603 (Alliance). Ann Surg 2015;262:434-9
[11] Wong, Stephanie M. MD et al. Growing Use of Contralateral Prophylactic Mastectomy Despite no Improvement in Long-term Survival for Invasive Breast Cancer. Annals of Surgery 265(3):p 581-589, March 2017
