Title: Post-Mastectomy Breast Reconstruction and Complications Swell Costs
Abstract: FigureSAN ANTONIO—The cost of undergoing a mastectomy with reconstruction—especially if complications occur—is the most expensive management of breast cancer surgery, researchers reported here at the San Antonio Breast Cancer Symposium (Abstract S3-07). A study of Medicare and other nationwide data sources determined that the average mastectomy plus reconstruction—and the estimated costs of complications—pushed the average cost of a mastectomy and breast reconstruction within two years to $89,140, reported Benjamin Smith, MD, Associate Professor of Radiation Oncology at the University of Texas MD Anderson Cancer Center. That compares with an outlay of $65,719 for a lumpectomy and 15 sessions of whole-body radiation, a standard-of-care treatment. It also includes the cost of related complications of the procedure, he said at a news conference. That translates to a $23,000 difference. The complications surrounding mastectomy and breast reconstruction can cost an average of $10,005, the analysis found. Those complications are most often infections, he noted, adding that lumpectomy with radiation has a complication cost of $1,397—about a $9,000 difference. “There is a twofold increase in complications with mastectomy and reconstruction compared with lumpectomy and whole-body radiation, resulting in excess costs. The complication costs are lowest with mastectomy alone among younger women—an average of $1,914—and for lumpectomy alone for older women—an average of $696. “Infectious complications are the most common we are seeing with mastectomy and reconstruction surgery,” Smith continued. “Many can be treated with just antibiotics, but some infections require procedures. We also see hematomas and seromas. These can all occur after any of these procedures, but are much more common with mastectomy and reconstruction surgery.” Costs for Older Women Much Lower Those figures represent the costs for younger women—i.e., those with a mean age of 53. The figures follow a similar course when looking at women and their choices for breast cancer management who are among the Medicare population—but the costs for the older women are dramatically lower. For example, total costs including complications for mastectomy and reconstruction top out at $36,166, which is about $2,000 more than lumpectomy and whole body radiation and complication costs or $34,097, Smith said. “The difference between mastectomy and reconstruction is not that much more expensive than lumpectomy—if you can avoid complications. Our findings represent what the average patient treated with these treatments can expect in the community setting. I would be the first to acknowledge that the use of claims codes is imperfect and may not capture the severity of the complications.” ‘These Results Make Perfect Sense’ Asked for his perspective for this article, Kevin Hughes, MD, Co-director of the Avon Breast Evaluation Center at Massachusetts General Hospital Cancer Center and Associate Professor of Surgery at Harvard Medical School, said: “Breast reconstruction is a much bigger operation and certainly you are going to have a greater risk of complications. These results make perfect sense. “There are increased costs of doing the operation, and increased costs of complications. The complications from surgery, however, are very rare. If they were common we would not do the procedure. The complication rate may run to 10 to 15 percent, but many of those complications are minimal and are self-limiting.” The cost analyses were developed by analyzing costs involved with 44,344 women from the MarketScan Commercial Claim and Encounters Database for the younger women and 60,867 women over age 65 selected from the SEER-Medicare database. “Women with early-stage breast cancer have several local therapy options. Although there's nuance as far as what treatment is best for which patient, there is a large group of patients for whom most, if not all, of these treatment options are considered guideline-appropriate,” Smith said. Current guideline-concordant local therapy options for women with early-stage breast cancer include lumpectomy plus whole breast irradiation, lumpectomy plus brachytherapy, mastectomy without reconstruction or radiation, mastectomy with reconstruction without radiation, and lumpectomy without radiation. Believed to Be First Such Study “Mastectomy and reconstruction rates have been increasing in the United States in the past decade, and I think ours is the first study to quantify the harm associated with choosing this procedure as opposed to simpler options,” he said. The investigators collected information on women who were diagnosed with early-stage breast cancer in 2000 through 2011 and had complete insurance coverage for a year before and two years after diagnosis. “When oncologists offer all appropriate therapy options to patients, some women may choose to avoid radiation and opt for mastectomy and reconstruction instead. This study is helpful to such patients because it provides them with information regarding the trade-offs involved in this choice,” Smith said. Hughes said that after the rates of mastectomies dropped as women began learning of lumpectomy surgery, the rates of mastectomy in the last decade have begun rising again. “This phenomenon is totally patient-driven. I think it is mostly fear of cancer. Lumpectomy has maybe a five percent chance of recurrence, but some women think that is too high—even though cancer can return after mastectomy as well.” The study was supported by grants from the Department of Health & Human Services, Varian Medical Systems, and the Duncan Family Foundation.