Comment on: Oncological, surgical, and cosmetic outcomes of endoscopic versus conventional nipple-sparing mastectomy: a meta-analysis

Correspondence to: Kefah Mokbel (email: kefahmokbel2@gmail.com)

The London Breast Institute

Princess Grace Hospital

42-52 Nottingham Place

London W1U 5NY

UK

BJS Open, https://doi.org/10.1093/bjsopen/zraf011, published 20 May 2025

We read with great interest the meta-analysis by Carroll et al.¹ comparing endoscopic and conventional nipple-sparing mastectomy (NSM). While the study offers a timely synthesis of data, several limitations deserve attention.

Firstly, selection bias remains a major concern. The endoscopic NSM cohort likely included patients with more favorable tumour characteristics and breast anatomy, yet the analysis lacks detailed data on molecular subtypes, tumour grade, and stage. These variables are essential when assessing oncological comparability. Additionally, the authors did not assess publication bias, omitting tools such as funnel plots or Egger’s tests, which could have identified overrepresentation of positive studies.

Secondly, the analysis reports improved aesthetic satisfaction in the endoscopic group, but the assessment was primarily based on visual analogue scales (VAS), which are subjective and highly susceptible to perception bias. More robust tools such as the BREAST-Q or objective image-based evaluations should have been employed to substantiate cosmetic outcomes, as highlighted in recent literature².

Thirdly, the longer operative time, use of specialized equipment, and extended hospital stays associated with endoscopic NSM strongly imply increased healthcare costs. However, the authors did not address cost-effectiveness—a key consideration in an era of constrained healthcare budgets².

Finally, margin status alone is an insufficient surrogate for long-term oncological safety. Follow-up durations in the included studies were relatively short, and this is particularly relevant for patients with hormone receptor–positive breast cancer and DCIS, where recurrences may occur years after surgery².

Future studies should address these limitations with stratified analyses, validated outcome measures, and long-term data to better inform the role of endoscopic NSM. Until the results of ongoing multicentre prospective studies such as MARRES3 become available, conventional NSM remains the gold standard, delivering excellent oncological and aesthetic outcomes backed by decades of evidence-based practice4.