The Cost of Contralateral Prophylactic Mastectomy in Women With Unilateral Breast Cancer

Jessica I. Billig, M.D.; Anthony Duncan, B.Sc.; Lin Zhong, M.D., M.P.H.; Oluseyi Aliu, M.D., M.S.; Erika D. Sears, M.D., M.S.; Kevin C. Chung, M.D., M.S.; Adeyiza O. Momoh, M.D.

Disclosures

Plast Reconstr Surg. 2018;141(5):1094-1102.

Abstract and Introduction

Abstract

Background: Contralateral prophylactic mastectomy may be unnecessary from an oncologic perspective; therefore, the debate persists about the value of contralateral prophylactic mastectomy in women with early-stage unilateral breast cancer. Given finite health care resources, this study aims to evaluate the cost of contralateral prophylactic mastectomy and breast reconstruction.

Methods: Women with unilateral breast cancer undergoing either unilateral mastectomy or unilateral mastectomy with contralateral prophylactic mastectomy and immediate breast reconstruction were selected from the Truven MarketScan databases between 2009 and 2013. Demographic and treatment data were recorded, and over an 18-month follow-up period, the treatment cost was tallied. A log-transformed linear model was used to compare cost between the groups.

Results: A total of 2343 women were identified who met our inclusion criteria, with 1295 undergoing unilateral mastectomy and 1048 undergoing contralateral prophylactic mastectomy. Complication rates within 18 months were similar for women undergoing unilateral mastectomy and contralateral prophylactic mastectomy (39 percent versus 42 percent; p = 0.17). Management with unilateral mastectomy with reconstruction required an adjusted cumulative mean cost of $33,557. Contralateral prophylactic mastectomy with reconstruction was an additional $11,872 in expenditure (p < 0.001). The cost of initial procedures (mean difference, $6467) and secondary procedures (mean difference, $2455) were the greatest contributors to cost.

Conclusions: In women with unilateral breast cancer, contralateral prophylactic mastectomy with reconstruction is more costly. The increased monetary cost of contralateral prophylactic mastectomy may be offset by improved quality of life. However, this financial reality is an important consideration when ongoing efforts toward reimbursement reform may not pay for contralateral prophylactic mastectomy if outcomes data are not presented to justify this procedure.

Introduction

Breast cancer is a substantial public health burden, with approximately 250,000 new cases of breast cancer diagnosed in 2016.^[1] Advances in breast cancer treatment and surveillance have led to improved 5-year survival. According to the Surveillance, Epidemiology, and End Results database, 89.7 percent of women with breast cancer survive at least 5 years after diagnosis.^[1] Despite improvements in detection, treatment, and survival, many women diagnosed with unilateral breast cancer are opting for contralateral prophylactic mastectomy to decrease their breast cancer–related risk in the contralateral breast.^[2,3]

The rate of contralateral prophylactic mastectomy has more than doubled in the past decade.^[4] This rising trend favoring contralateral prophylactic mastectomy continues despite the absence of a clear survival advantage over unilateral mastectomy.^[5–7] This may be attributable in part to nononcologic benefits, including quality of life from the patient's perspective. Women undergoing contralateral prophylactic mastectomy with immediate breast reconstruction have been reported to have an improvement in breast cancer–related anxiety and satisfaction with their breasts.^[8,9] These intangible benefits may be drivers in the decision for contralateral prophylactic mastectomy. Nevertheless, concerns exist in the oncologic community about this trend. The American Society of Breast Surgeons recently produced a consensus statement advising against contralateral prophylactic mastectomy in average-risk women, in whom the procedure does not provide oncologic benefit.^[10]

With the notion that contralateral prophylactic mastectomy is potentially unnecessary from an oncologic standpoint in many patients, information on the financial burden of contralateral prophylactic mastectomy on the health care system is needed. Single-institution studies have demonstrated higher short-term health care costs of contralateral prophylactic mastectomy in average-risk women.^[11] In contrast, cost-effectiveness of contralateral prophylactic mastectomy compared with routine surveillance has been demonstrated for average-risk women younger than 70 years.^[12] However, little is known about the cost of contralateral prophylactic mastectomy with immediate breast reconstruction on the national level. Thus, the purpose of our study is to evaluate health care resource use with mastectomy and reconstruction in women undergoing unilateral mastectomy and contralateral prophylactic mastectomy using a nationwide database.

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Table 1. Patient Clinical Characteristics and Demographic Data
Patient Characteristics	Unilateral Mastectomy (%)	CPM (%)	p
Total	1295 (55)	1048 (45)
Type of reconstruction			0.32
Implant	1122 (87)	892 (85)
Autologous	173 (13)	156 (15)
Age			<0.001
18–34 yr	48 (4)	74 (7)
35–44 yr	249 (19)	286 (27)
45–54 yr	546 (42)	419 (40)
55–64 yr	369 (28)	225 (21)
≥65 yr	83 (6)	44 (4)
Quartile of median household income			0.03
1 (≤$46,910)	217 (17)	132 (13)
2 ($46,910–$51,920)	217 (17)	185 (18)
3 ($51,920–$58,900)	358 (28)	309 (29)
4 (>$58,900)	350 (27)	306 (29)
Missing	153 (12)	116 (11)
Comorbidity score quartile			0.004
1 (≤12)	328 (25)	290 (28)
2 (13–20)	284 (22)	204 (19)
3 (21–27)	281 (22)	178 (17)
4 (≥27)	402 (31)	376 (36)
Region			<0.001
Northeast	266 (21)	287 (27)
North central	297 (23)	224 (21)
South	445 (34)	300 (29)
West	262 (20)	221 (21)
Missing	25 (2)	16 (2)
Chemo within 18 mo			<0.001
No	873 (67)	792 (76)
Yes	422 (33)	256 (24)

CPM, contralateral prophylactic mastectomy.

Table 2. Complication Rates
Unilateral Mastectomy (%)		CPM (%)	p
Complications within 30 days			0.34
No	1139 (88)	907 (87)
Yes	156 (12)	141 (13)
Complications within 18 mo			0.17
No	790 (61)	609 (58)
Yes	505 (39)	439 (42)

CPM, contralateral prophylactic mastectomy.

Table 3. Clinic and Hospital Use within 18 Months after Reconstruction
Patient Characteristics	Unilateral Mastectomy (%)	CPM (%)	p
Clinic visits			<0.001
≤4	328 (25)	396 (38)
5–8	338 (26)	228 (22)
9–14	309 (24)	214 (20)
>14	320 (25)	210 (20)
ED visits			0.006
No	1149 (89)	966 (92)
Yes	146 (11)	82 (8)
Hospital readmission			0.60
No	1086 (84)	888 (85)
Yes	209 (16)	160 (15)

CPM, contralateral prophylactic mastectomy; ED, emergency department.

Table 4. Mean Cost of Use Comparing Unilateral Mastectomy to Contralateral Prophylactic Mastectomy
	Unilateral Mastectomy (SD)	CPM (SD)	p*
Cumulative cost within 18 mo	$33,557 ($44,072)	$37,811 ($44,885)	<0.001
Cost of index procedures	$10,628 ($15,088)	$17,095 ($26,309)	<0.001
Cost of adjuvant chemotherapy	$12,438 ($33,033)	$9117 ($32,049)	<0.001
Cost of complications within 30 days	$1593 ($15,307)	$1738 ($10,476)	0.222
Cost of complications within 18 mo	$4627 ($17,807)	$4722 ($13,384)	0.118
Cost of secondary procedures within 18 mo	$5862 ($6986)	$8317 ($12,567)	<0.001
Cost of clinic visits	$1543 ($2503)	$1260 ($1300)	<0.001
Cost of ED visits within 18 mo	$232 ($2633)	$378 ($5946)	0.008
Cost of readmission within 18 mo	$2746 ($10,290)	$1983 ($8051)	0.383

CPM, contralateral prophylactic mastectomy; ED, emergency department.
*p <0.05 denotes statistical significance.

Table 5. Cost of Use Separated by Reconstruction Type
	Unilateral Mastectomy (SD)	CPM (SD)	p*
Autologous-based reconstruction
Cumulative cost within 18 mo	$49,013 ($53,148)	$68,492 ($59,690)	<0.001
Cost of index procedures	$27,439 ($25,978)	$48,902 ($48,629)	<0.001
Cost of adjuvant chemotherapy	$11,797 ($38,285)	$10,232 ($36,645)	0.602
Cost of complications within 30 days	$6813 ($18,052)	$7349 ($21,058)	0.483
Cost of complications within 18 mo	$3498 ($13,963)	$5953 ($20,427)	0.057
Cost of secondary procedures within 18 mo	$4898 ($6662)	$9310 ($17,263)	0.248
Cost of clinic visits	$1339 ($1657)	$1096 ($1187)	0.029
Cost of ED visits within 18 mo	$536 ($6044)	$117 ($796)	0.378
Cost of readmission within 18 mo	$3701 ($15,699)	$2095 ($8616)	0.908
Implant-based reconstruction
Cumulative cost within 18 mo	$31,174 ($42,025)	$32,446 ($39,421)	<0.001
Cost of index procedures	$8036 ($10,436)	$11,533 ($13,924)	<0.001
Cost of adjuvant chemotherapy	$12,537 ($32,165)	$8922 ($31,195)	<0.001
Cost of complications within 30 days	$4290 ($17,753)	$4263 ($11,487)	0.160
Cost of complications within 18 mo	$1299 ($15,489)	$1001 ($7262)	0.847
Cost of secondary procedures within 18 mo	$6010 ($7026)	$8143 ($11,556)	<0.001
Cost of clinic visits	$1574 ($2608)	$1288 ($1318)	<0.001
Cost of ED visits within 18 mo	$185 ($1543)	$424 ($6436)	0.013
Cost of readmission within 18 mo	$2599 ($9179)	$1963 ($7953)	0.326

CPM, contralateral prophylactic mastectomy; ED, emergency department.
*p <0.05 denotes statistical significance.

Table 6. Linear Log Logistic Regression of Reconstruction and Cost
	Adjusted Mean Difference in Cumulative Cost (95% CI)	p	Adjusted Mean Cumulative Cost
Mastectomy laterality
Unilateral	Ref	Ref	$33,557
Bilateral	$11,872 ($8920–$15,029)	<0.001	$45,429
Type of reconstruction
Implant	Ref	Ref	$31,737
Autologous	$37,136 ($31,016–$43,853)	<0.001	$68,873
Complications
No	Ref	Ref	$29,663
Yes	$15,370 ($12,349–$18,608)	<0.001	$45,033
Age
18–34 yr	Ref	Ref	$36,666
35–44 yr	−$482 (−$5853 to $5826)	0.872	$36,185
45–54 yr	−$1388 (−$6445 to $4516)	0.625	$35,278
55–64 yr	−$4198 (−$9030 to $1480)	0.139	$32,469
≥65 yr	−$1852 (−$8219 to $5941)	0.615	$34,815
Quartile of median household income
1 (≤$46,910)	Ref	Ref	$32,031
2 ($46,910–$51,920)	$2347 (−$1211 to $6316)	0.205	$34,377
3 ($51,920–$58,900)	$1531 (−$1621 to $5009)	0.354	$33,561
4 (>$58,900)	$11,183 ($7108–$15,683)	<0.001	$43,214
Comorbidity score quartile
1 (≤12)	Ref	Ref	$31,903
2 (13–20)	−$1217 (−$4034 to $1884)	0.428	$34,377
3 (21–27)	$1301 (−$1834 to $4763)	0.43	$33,561
4 (≥27)	−$891 (−$3434 to $1879)	0.517	$43,214
ED visits
No	Ref	Ref	$33,339
Yes	$3491 (−$370 to $7803)	0.078	$36,830
Readmissions
No	Ref	Ref	$31,349
Yes	$22,048 ($17,210–$27,368)	<0.001	$53,396
No. of clinic visits within 18 mo
≤4	Ref	Ref	$24,408
5–8	$2040 (−$239 to $4535)	0.081	$26,448
9–14	$1280 (−$981 to $3759)	0.277	$25,688
>14	−$357 (−$2554 to $2060)	0.763	$24,051