Mastectomy Pricy Option for Early Breast Cancer

Neil Osterweil

December 10, 2015

SAN ANTONIO, Texas — The complication rate associated with mastectomy and reconstruction of early breast cancer is nearly twice that for lumpectomy and whole-breast irradiation, leading to a substantially higher price tag for the more invasive surgery, results of a new study show.

A review of data on more than 44,000 women aged 65 years or under in a commercial claims database and nearly 61,000 women aged 66 years or older in a Medicare database show that when the total cost of therapy and near-term complications are factored in, mastectomy with reconstruction costs from $2,000 to $23,000 dollars more per case than lumpectomy and radiation, reported Benjamin D. Smith, MD, associate professor of radiation and health services research at the University of Texas MD Anderson Cancer Center in Houston.

"Our data would suggest that lumpectomy plus whole-breast irradiation is a high value treatment for younger women, and either lumpectomy alone or lumpectomy plus whole breast irradiation are the highest value treatments for older women," he said at the 38th San Antonio Breast Cancer Symposium here.

The value of lumpectomy and radiation could be further improved by the use of hypofractionated radiation schedules, he said.

Value Not in the Equation

Dr Benjamin Smith

Approximately 140,000 women are diagnosed with early breast cancer annually in the United States, and most are eligible for several localized disease treatment options, including lumpectomy with our without whole-breast irradiation or brachytherapy, and mastectomy with or without reconstruction. Studies have shown that when these options are applied appropriately, there is no significance difference in overall survival rates, Dr Smith said.

Nearly 40% of women with early breast cancer opt to undergo mastectomy, and of these women, nearly 40% choose to have reconstruction. Dr Smith said that the reasons for choosing mastectomy range from medical indications (multifocality, centricity, genetics) to patient fears and misconceptions such as a fear of recurrence or an "underestimated appraisal of harm" from more extensive surgery.

Yet value — the balance between costs and outcomes — is rarely taken into consideration, he added.

To get a better handle on the relative value of local therapy options for early breast cancer, the investigators compared the complication burdens, total costs, complication-related costs, and noncomplication costs for each option.

They drew data on 44,344 women aged 65 years or younger with early breast cancer from the MarketScan Commercial Claims and Encounters database and 60,867 women aged 66 years or older in the Surveillance, Epidemiology and End Results (SEER) Medicare database.

They defined complications from local therapy as a diagnostic or procedure code within 2 years for wound complications, local infections, seroma or hematoma, fat necrosis, breast pain, pneumonitis, rib fracture, implant removal, or graft failure.

Complication Rates for Each Cohort

Procedure Type MarketScan SEER-Medicare
Lumpectomy/WBI 30% 38%
Lumpectomy/Brachytherapy 45% 51%
Lumpectomy alone 31% 31%
Mastectomy no reconstruction 25% 37%
Mastectomy + reconstruction 56% 69%

The authors also looked at total costs from diagnosis to month 24, complication costs (costs on days a complication occurred), and noncomplication costs (total minus complication costs).

 

Total Costs by Procedure

Procedure Type MarketScan SEER-Medicare
Lumpectomy/WBI $65,719 $34,097
Lumpectomy/Brachytherapy $77,245 $37,741
Lumpectomy alone $70,803 $21,154
Mastectomy no reconstruction $48,758 $22,424
Mastectomy + reconstruction $89,140 $36,166

Patients, clinicians, and insurers may find these data useful when planning treatment for early breast cancer, Dr Smith said, but he cautioned that some patients may benefit from mastectomy with reconstruction rather than the less invasive option, and expressed hope that the data would not be used to deny women coverage for the more expensive procedures.

He also acknowledged that the study looked only at early complications of surgery, and that complications occurring after that could have an effect on the relative costs of care for each type of therapy.

A breast surgeon who was not involved in the study told Medscape Medical News that the data need to be interpreted with caution.

"It seems that if you're a younger woman, having mastectomy alone is actually the most cost-effective option, and if you're an older woman having a lumpectomy alone is the most cost-effective option. But I think that these data need to be interpreted in the context of patients' preferences and their disease biology as well, said Anees B. Chagpar, MD, MPH, director of the Breast Center at Smilow Cancer Hospital at Yale-New Haven Hospital in Connecticut.

She said that the short-term complication rates reported were in line with expectations, but noted that there are longer-term complications of both radiation and reconstruction that need to be taken into account.

"The other thing that was not taken into account was the cost of screening. With mastectomy, you're not going to have breast imaging for the rest of your life, whereas with lumpectomy you are. So these cost data are interesting and have validity on the face, but we always need to think about the other factors that go into making these decisions as well," she said.

The study was supported by grants from the Department of Health and Human Services, Varian Medical Systems, and the Duncan Family Foundation.

Dr Smith and Dr Chagpar have disclosed no relevant financial relationships.

San Antonio Breast Cancer Symposium (SABCS) 2015: Abstract S3-07. Presented December 10, 2015.

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