Single Mastectomy a More Cost-Effective Treatment for Nonhereditary Cancer in One Breast than Removing Both Breasts
Robert C. Keskey
AMERICAN COLLEGE OF SURGEONS
2015 Clinical Congress
October 4-8, 2015
NICOLAS AJKAY, MD, FACS
ROBERT C. KESKEY
CHICAGO: For younger women with early-stage, noninherited breast cancer on one side, a unilateral, or single, mastectomy leads to a slightly higher quality of life and lower costs over the next 20 years compared with contralateral prophylactic mastectomy (CPM), according to new study results presented at the 2015 Annual Clinical Congress of the American College of Surgeons. The quality of life and cost-effectiveness analysis was conducted in women under age 50 who had the most common type of breast cancer—sporadic, meaning no family history of the disease.
U.S. women with unilateral breast cancer are increasingly choosing CPM, which is the surgical removal of the healthy breast along with the cancerous one to prevent the risk of breast cancer occurring in the healthy breast. One national study reported that the CPM rate increased from 1.9 percent in 1998 to 10.2 percent in 2011.1 However, there is no strong evidence that prophylactic mastectomy improves survival for women with sporadic breast cancer,2 and a double mastectomy poses nearly double the risk of postoperative complications.3 On the other hand, most women who have both breasts removed do not need annual screening mammograms.4
Researchers, led by Nicolas Ajkay, MD, FACS, assistant professor of surgery at the University of Louisville School of Medicine in Louisville, Ky., conducted this study to help patients and their surgeons in the decision-making process about which operation to choose. Using a decision tree/probabilities model,5 the researchers compared the estimated long-term costs of each operation, follow-up care, and the patient’s health-related quality of life after the operation, assuming both ideal and poor outcomes.
“Even under worst-case scenarios, we found that costs and quality of life were superior with unilateral mastectomy,” Dr. Ajkay said. “With our study results, I can counsel patients that they may incur a higher cost over their lifetime with a lower quality of life for several months if they choose CPM.’”
Single mastectomy plus 20 years of routine mammograms on the remaining breast costs, on average, $5,052 less than CPM ($13,525 versus $18,577), the research team reported. In estimating costs, the investigators took into account physician and imaging fees, hospitaliza-tion, other cancer treatments, and cost-of-living expenses, with all data from 2014 or adjusted to 2014 costs.
From the recent medical literature, the researchers derived the probabilities of ideal outcomes and poor outcomes over 10 years, both with and without breast reconstruction. Poor outcomes included wound complications requiring another operation and, in cases of single mastectomy, the development of breast cancer in the opposite breast five and 10 years later.
To estimate patients’ quality of life, Dr. Ajkay and colleagues used the health-related quality of life measure of a quality-adjusted life year (QALY),6 in which a year in perfect health has a rating of 1.0 QALY. After 20 years of follow-up care, women who underwent unilateral mastectomy had a net gain of 0.21 QALYs (14.75 versus 14.54 QALYs), which Dr. Ajkay said equates to approximately three months of improved health and quality of life.
For a woman who chooses CPM, a QALY loss of 0.21, according to Dr. Ajkay, could mean “about three months of struggling with surgical complications of reconstruction, lost work productivity, and significant emotional hardship.”
Because women who undergo unilateral mastectomy have a much lower rate of breast reconstruction than those who opt for CPM, the researchers also calculated probabilities assuming that all women undergoing single mastectomy also had reconstruction. In that scenario, the cost and QALY were still better than for CPM, according to the study abstract. For an ideal outcome with reconstruction, unilateral mastectomy and screening mammograms reportedly cost $19,158, or $1,234 less than the $20,392 cost of CPM, and the QALY was 0.20 better than that with CPM.
Dr. Ajkay cautioned however that their study results do not apply to women with a familial or genetic risk of breast cancer, who were excluded from participating in this study. He said, “In most clinicians’ view, these patients do benefit from CPM.”
Robert C. Keskey, a fourth-year medical student from the University of Louisville School of Medicine, presented the study results. Other research colleagues for the study were: Amanda Roberts, MD, MPH, University of Toronto; Kevin D. Frick, PhD, Johns Hopkins University, Baltimore; and Andrew S. LaJoie, PhD; In K. Kim, MD, MBA; Brad S. Sutton, MD, MBA; and William G. Cheadle, MD, FACS, all from University of Louisville School of Medicine.
“FACS” designates that a surgeon is a Fellow of the American College of Surgeons.
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1Grimmer L, Liederbach E, Velasco J, Pesce C, Wang CH, Yao K. Variation in Contralateral Prophylactic Mastectomy Rates According to Racial Groups in Young Women with Breast Cancer, 1998 to 2011: A Report from the National Cancer Data Base. J Am Coll Surg. 2015;221(1):187-196.
2 National Comprehensive Cancer Network. Updated NCCN Guidelines for Breast Cancer Discourages Prophylactic Mastectomy in Women Other Than Those at High Risk. Press release. October 28, 2009. Available at: http://www.nccn.org/about/news/newsinfo.aspx?NewsID=226. Accessed August 17, 2015.
3 Osman F, Saleh F, Jackson TD, Corrigan MA, Cil T. Increased Postoperative Complications in Bilateral Mastectomy Patients Compared to Unilateral Mastectomy: An Analysis of the NSQIP Database. Ann Surg Oncol. 2013;20(10):3212-3217.
4 American Cancer Society. Mammograms After Breast Cancer. Revised April 9, 2015. Available at http://www.cancer.org/healthy/findcancerearly/examandtestdescriptions/mammogramsandotherbreastimagingprocedures/mammograms-and-other-breast-imaging-procedures-mamm-after-breast-cancer. Accessed August 7, 2015.
5 Roberts A, Habibi M, Frick KD. Cost-Effectiveness of Contralateral Prophylactic Mastectomy for Prevention of Contralateral Breast Cancer. Ann Surg Oncol. 2014;21(7):2209-2217.
6 Peasgood T, Ward S, Brazier J. A Review and Meta-Analysis of Health State Utility Values in Breast Cancer. Scheffield, UK: University of Sheffield School of Health and Related Research; 2010 (unpublished). Updated June 12, 2014. Health Economics and Decision Science (HEDS) Discussion Paper 10/15. Available at http://eprints.whiterose.ac.uk/74336. Accessed August 17, 2015.
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About the American College of Surgeons
The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 80,000 members and is the largest organization of surgeons in the world. For more information, visit www.facs.org (.)