Abstract and Introduction
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.
Breast cancer is a substantial public health burden, with approximately 250,000 new cases of breast cancer diagnosed in 2016. 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. 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. 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.
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. In contrast, cost-effectiveness of contralateral prophylactic mastectomy compared with routine surveillance has been demonstrated for average-risk women younger than 70 years. 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.
Plast Reconstr Surg. 2018;141(5):1094-1102. © 2018 Lippincott Williams & Wilkins