Single Mastectomy Saves Money Compared With Double Mastectomy

Lara C. Pullen, PhD

October 12, 2015

CHICAGO — Younger women who elect to undergo unilateral mastectomy (UM) with routine surveillance gain several months of life in optimal health in comparison with patients choosing contralateral prophylactic mastectomy (CPM). This is the conclusion of a new analysis, which applies only to women with no family history of breast cancer.

"Contralateral prophylactic mastectomy was more expensive and provided a lower quality of life," emphasized Robert C. Keskey, of the University of Louisville School of Medicine, in Kentucky.

He noted that the rate of CPM has increased from 1.9% in 1998 to 10.2% in 2011.

Although UM continues to dominate CPM in the treatment of unilateral sporadic breast cancer, CPM rates are increasing rapidly.

There is, however, no strong evidence to support the ability of prophylactic mastectomy to improve survival for women with sporadic breast cancer, he noted.

Keskey presented the results of his cost-effectiveness analysis here at the American College of Surgeons (ACS) Clinical Congress 2015. The study was conducted to help patients and surgeons choose the appropriate operation, he said.

"Even under worst-case scenarios, we found that costs and quality of life were superior with unilateral mastectomy," said senior investigator Nicolas Ajkay, MD, also at the University of Louisville School of Medicine, in a press release. "With our study results, I can counsel patients that they may incur a higher cost over their lifetime with a lower quality of life for several months if they choose CPM."

"I congratulate the authors for tackling an important issue," said discussant Judy C. Boughey, MD, of the Mayo Clinic, in Rochester, Minnesota. She added, however, that her own research revealed that "if a patient felt that their quality of life was improved by a CPM, then it was cost-effective." Moreover, other published studies on the subject have found that CPM is cost- effective for patients up to the age of 70 and that it provides cost savings but a lower quality of life.

The presentation ended with an audience member saying, "I am concerned about using these data in the future for denying payment for contralateral procedures." The audience murmured in agreement.

Details of the Analysis

The researchers used a decision-tree model in TreeAge Pro 2015 to compare long-term costs and quality of life for patients younger than 50 years who chose UM with routine surveillance and compared those results to results from patients who chose CPM for sporadic breast cancer. The investigators did not include in their analysis women who underwent UM and then underwent symmetry surgery.

The cost-effectiveness model focused on a 45-year-old woman diagnosed with unilateral, sporadic breast cancer. The majority of the costs in the analysis were taken from the Centers for Medicare and Medicaid Services physician fee schedule.

Effectiveness was measured by quality adjusted life-years (QALYs). Keskey acknowledged that such a measure is subjective in nature.

Treatment with UM resulted in $4109 in cost savings relative to CPM as well as a gain of 0.21 QALYs during 20 years of follow-up.

Table. Cost-effectiveness Analysis

Outcomes After Unilateral, Sporadic Breast Cancer Treatment With CPM or UM UM Cost ($) UM QALY CPM Cost ($) CPM QALY
All possible outcomes averaged 10,185 14.74 14,294 14.54
Ideal outcome without reconstruction: no surgical complications; no CBC 8,509 19.71 9,965 19.51
Poor outcome with reconstruction: no surgical complication; no CBC 13,356 19.69 14,920 19.49
Poor outcome without reconstruction: surgical complications; CBC at 5 years 35,359 17.67 37,041 17.47
Poor outcome with reconstruction: surgical complications; CBC at 5 years 40,404 17.65 42,194 17.45

 

The authors and Dr Boughey have disclosed no relevant financial relationships.

American College of Surgeons (ACS) Clinical Congress 2015: Presented October 6, 2015.

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