Costs of Breast Cancer Surgery Can Be
Financial Burden

Fran Lowry

August 08, 2019

Women newly diagnosed with breast cancer face important decisions about their surgical treatment. For many, those decisions are guided by cost.

In a survey of more than 600 women with a history of breast cancer, 43% of respondents reported they considered costs when making treatment decisions, and one third reported that their cancer treatment created a financial burden that in some cases was catastrophic.

The women also said knowing the cost of their treatment beforehand would have been beneficial, but that the subject was never discussed with their healthcare team.

Most of the women were white, well-educated, privately insured, and more than half reported household incomes greater than $74,000.

The findings were published online July 29 in the Journal of Oncology Practice.

Dr Rachel Greenup

"Financial toxicity, defined as cancer-related financial hardship, has become a growing problem among cancer patients," lead author Rachel A. Greenup, MD, MPH, a surgeon at Duke Cancer Institute, Duke University, Durham, North Carolina, told Medscape Medical News.

"Historically, there was a misconception that only uninsured individuals were at risk, but research has shown that out-of-pocket costs are burdensome to families, even among the insured," Greenup said.

Eligible women with breast cancer have several surgical options: they may choose breast conserving surgery with radiation, or mastectomy with or without reconstruction, and, increasingly, contralateral prophylactic mastectomy.

"Breast cancer is unique in that decisions for breast cancer surgery are really preference sensitive, taking into account a woman's goals and values, and we make those decisions with patients in a shared decision-making process," Greenup said.

"We have decades worth of data demonstrating that lumpectomy with radiation is equally effective to mastectomy, and increasingly, many women are choosing to undergo contralateral prophylactic mastectomy with removal of the unaffected breast. Surgeons routinely discuss each treatment option with women and review the pros and cons of each choice. However, transparency has been lacking about the financial costs and burden related to surgical choice, including time off work, frequent hospital visits, paying for parking, and child care," she said.

Greenup and her team conducted an 88-question electronic survey of 607 women ages 18 and older who had been diagnosed with stage 0–III breast cancer. Median time from diagnosis was 6.7 years.

The women were recruited from members of the Army of Women, a national coalition of breast cancer survivors and activists, and the Sisters Network of North Carolina, an African American breast cancer survivors' group.

Their demographic profile was substantially more affluent than the US average: 90% were white, 70% had private health insurance, 25% had Medicare, 78% were college educated, and 56% reported household incomes above $74,000 a year.

The most common surgical treatment that was chosen was breast conserving surgery in 43%; another 25% underwent mastectomy, 32% underwent bilateral mastectomy, and 36% had breast reconstruction.

Median reported out-of-pocket costs were $3,500. However, 25% of the women reported out-of-pocket costs of $8,000 or more, 10% reported out-of-pocket costs of $18,000 or more, and 5% reported out of pocket costs of $30,000 or more.

Additionally, 15.5% of respondents reported significant to catastrophic financial burden as a result of the surgery.

Factors that were associated with a higher risk of financial harm included bilateral mastectomy with or without reconstruction vs lumpectomy (odds ratio [OR], 1.9; P = .03); greater stage at diagnosis (stage III vs stage 0; OR, 3.9; P = .01); and discussion of cost during the clinical encounter: (OR, 2.3; P < .01).

Compared with those who did not discuss costs with their cancer care team, women who reported discussing costs were more likely to have stage II or III cancer (56% vs 40%, P = .02), less likely to be depressed (24% vs 30%, P = .03), and have less insurance coverage (trend P = .02).

Older age at diagnosis, increasing household income, better insurance coverage, and longer time since diagnosis were all associated with a decreased risk of financial harm.

Cost Consideration More Important Than Appearance

For women whose household incomes were under $45,000 per year, costs of treatment were more important than keeping their breast or its appearance.

"Many of the very low income participants in my study cared far more about saving money or protecting their finances than keeping their breast," Greenup commented.

"We talk to women at length about the appearance of their breast after surgery and how easily we can keep their breast and the options for reconstruction," she added. "But I don't believe we're giving authentic comprehensive information about how these choices that we are allowing them to make can impact their financial and personal well-being."

"It is critical that breast cancer patients are aware of how these choices might impact their finances," Greenup emphasized.

"Regardless of what surgical choice women make, they do equally well, and so this is an opportunity to give them cost and burden information without negatively impacting their cancer care," she added.

Greenup emphasized that doctors need not fear having to add a discussion about cost to their already lengthy to-do list for their patients.

"Physicians understandably have concerns about taking on another discussion point, but it is important that oncologists have a heightened awareness that every patient has the potential to be impacted by financial toxicity, and to ask patients if money is a concern for them," Greenup said.

Possessing health insurance does not protect against financial harm.

"We need to change the perception that having insurance entirely protects you from financial hardship," she stressed. "Even among insured individuals, evidence suggests that deductibles, copayments, time off work for patients and their caregivers, are all financially burdensome. This is especially true among young, minority, privately insured individuals as opposed to Medicare beneficiaries.

"Furthermore, patients overwhelmingly desired information regarding the costs of their cancer treatment, and 80% never had cost discussions with any member of their cancer team."

A limitation of the study is its use of the Army of Women database, Greenup noted.

"The Army of Women includes a high rate of white women with advanced education, insurance coverage, and higher household incomes. In addition, members of both the Army of Women and the Sisters Network include women actively engaged in research and survivorship efforts. Our findings may not be generalizable and in fact may underestimate the risk of treatment-related financial harm when compared to the overall population of women with breast cancer," she said.

Greenup said any subsequent studies that she conducts on the financial aspect of breast cancer surgery will include a more culturally diverse mix of patients.

"Our future research will address how costs relate to decisions for breast cancer surgery in a more diverse population of women at the time of diagnosis," she said. "Patients must receive this information in an understandable format that does not add to their distress."

Greenup has disclosed no relevant financial relationships. The work was supported by the National Institutes of Health's Building Interdisciplinary Research Careers in Women's Health (BIRCWH) Career Development Award, and Duke Cancer Institute.

J Oncol Prac. Published online July 29, 2019. Abstract

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