This article is more than 5 years old. Information may no longer be current.
Reconstruction after mastectomy increases complication rates, cost
Click Here to Manage Email Alerts
SAN ANTONIO — Mastectomy with breast reconstruction led to a nearly twofold increased risk for complications as well as higher cost compared with other surgical options for younger and older women with early breast cancer, according to study results.
Available local treatment options for women diagnosed with early breast cancer in the U.S. include lumpectomy alone or with whole-breast irradiation or brachytherapy, or mastectomy alone or with breast reconstruction.
Benjamin D. Smith
“When patients receive local therapy that’s concordant with guidelines, their survival is essentially equivalent regardless of the local therapy chosen; however, these local therapies differ significantly in the extent of surgery and the radiation that is delivered,” Benjamin D. Smith, MD, associate professor in the department of radiation oncology at The University of Texas MD Anderson Cancer Center, said during a press conference.
Further, the rates of mastectomy have increased over time, Smith said. Data from Kummerow and colleagues have shown that the proportion of women who underwent mastectomy increased significantly between 2005 and 2011, and approximately 40% of these women also received post-mastectomy reconstruction.
Medical indications for mastectomy include multifocality/centricity, as well as having a heritable genetic syndrome. However, patient fears and misperceptions may also them to choose mastectomy, Smith said.
“Notably absent is the concept of value when making determinations about the best local therapy for women with early breast cancer,” he said. “In light of this background, our primary objective was to improve the understanding of the value of local treatment options for early breast cancer by comparing their complication burden, total cost, complication-related cost and non–complication-related cost.”
Smith and colleagues evaluated data from two non-overlapping cohorts derived from the MarketScan Commercial Claims and Encounters Database (n = 44,344; median age, 53 years) as well as SEER–Medicare data (n = 60,867; median age, 75 years) to answer these questions.
Researchers searched these databases for codes for complications associated with breast surgical procedures, such as wound complication, infection, hematoma/seroma, breast pain and rib fracture. To assess costs (in 2014 dollars), they evaluated claims that occurred between diagnosis and 24 months after diagnosis. Researchers defined complication-related costs as the sum of all costs that occurred on days when a complication was noted in insurance claims. They defined non–complication-related costs — or the baseline cost of the treatments without complications — as the difference between total costs and complication costs.
Rates of treatment, complications
The most common treatment was lumpectomy plus whole-breast radiation in the MarketScan (38%) and SEER–Medicare (49%) cohorts. Mastectomy alone occurred in 26% of the MarketScan cohort and 31% of the SEER–Medicare cohort, but a greater proportion of patients in the MarketScan cohort underwent mastectomy with reconstruction (26% vs. 3%).
Mastectomy plus reconstruction appeared significantly associated with a higher rate of any complication compared with other treatments in the MarketScan (36%) and SEER–Medicare (69%; P ˂ .001 for both) cohorts, although Smith noted the rates of complications were generally higher in the SEER–Medicare cohort. Treatments with the lowest complication rate were mastectomy alone in the MarketScan cohort (25%) and lumpectomy alone in the SEER–Medicare cohort (31%).
Models adjusted for age, race, comorbidity and other factors showed mastectomy plus radiation increased risk for any complication nearly twofold compared with lumpectomy plus whole-breast radiation in the MarketScan cohort (RR = 1.94; 95% CI, 1.9-1.98) and SEER–Medicare cohort (RR = 1.82; 95% CI, 1.76-1.88).
Lumpectomy plus brachytherapy also appeared to increase risk for complications, although to a lesser degree, in the MarketScan cohort (RR = 1.46; 95% CI, 1.4-1.52) and SEER–Medicare cohort (RR = 1.36; 95% CI, 1.31-1.41).
Costs
When evaluating total costs, mastectomy plus reconstruction was the most expensive treatment in the MarketScan cohort ($89,140) whereas mastectomy alone was the least expensive ($48,758). In the SEER–Medicare cohort, lumpectomy plus brachytherapy was the most expensive treatment ($37,741) and lumpectomy was the cheapest ($21,154).
Complication costs from mastectomy plus reconstruction were $10,005 per patient in the MarketScan cohort — which represented a $9,000 increase compared with lumpectomy plus whole-breast irradiation — and $3,264 per patient in the SEER–Medicare cohort, or a $2,500 increase compared with lumpectomy plus whole-breast irradiation.
In the MarketScan cohort, mastectomy plus reconstruction had the highest non-complication costs ($78,842), which were approximately $15,000 higher than costs associated with lumpectomy plus whole-breast irradiation. However, in the SEER–Medicare cohort, non-complication costs were approximately $700 less with mastectomy and reconstruction than with lumpectomy plus whole-breast radiation ($32,743 vs. $33,413).
“This indicates that mastectomy plus reconstruction is not terribly more expensive, if you can avoid complications,” Smith said.
Not all patients in these cohorts may have been eligible for every treatment, so these results may only reflect the average patient treated with these modalities in the community setting, Smith said. Assessing complications with claims codes may be another limitation.
“These findings are most relevant to patients and payers when contemplating initial management, and both lumpectomy and mastectomy are viable treatments options for a patient,” Smith said. “However, if mastectomy is performed, reconstruction is generally considered to be a high-value intervention, and it would be inappropriate to conclude otherwise from the data that have been presented.” – by Alexandra Todak
References:
- Smith BD, et al. Abstract S3-07. Presented at: San Antonio Breast Cancer Symposium; Dec. 8-12, 2015; San Antonio.
- Kummerow KL, et al. JAMA Surg. 2014;doi:10.1001/jamasurg.2014.2895.
Disclosure: The study was funded in part by Varian Medical Systems. The researchers report no relevant financial disclosures.
Perspective
Back to Top
Amy C. Degnim, MD
For women with early-stage disease who have multiple options for treatment, the choice of mastectomy with reconstruction is a higher-cost option and also has a higher rate of complications. This is important information for those of us in the medical community to know, as it helps us understand that — in addition to having different potential therapeutic ramifications — there are cost differences between these treatments. This information may be very important to women as they are making their treatment choices.
There are a few concerns about the study. One is that the presented information on costs and complications was from the first 2 years after treatment. These are really lifetime decisions, so in order to present a balanced view of costs, we really need to look much farther down the road. For example, for women who had mastectomy with reconstruction or mastectomy alone, we would expect their costs to be greater early. However, in the long run, they would have less surveillance and their costs may be lower, so this may balance out over time.
Another issue is that, in this study, all types of complications are given equal weight. Some complications — such as seroma, or a small collection of fluid under the skin — may be relatively inconsequential compared with other types of complications, such as implant removal or needing to completely deconstruct the breast reconstruction. It may be more informative for women to know what the risks are for what we would consider serious complications, and I would expect those would be lower than the complete list of complications that were presented.
One of the important take-home messages from this work is we need to understand what the costs of treatment are. Those include financial costs, as well as the costs of suffering or complications. We need to focus not only on the short term, but how these play out over the long term.
The final factor that wasn’t taken into account in this study is women’s satisfaction with their choices. How pleased are they with the choices they have made and did this fulfill their goals of treatment? Those are important pieces we’ll want to look at as we bring this information to bear and use it to guide women’s choices for treatment.
Click Here to Manage Email Alerts