Photo ©MedMeetingImages/Todd Buchanan 2015
Benjamin D. Smith, MD
The risk of complications from mastectomy plus reconstruction was increased by two-fold compared with lumpectomy plus whole breast irradiation after adjustment for other treatment differences in both younger and older patients with private insurance or Medicare, reported Benjamin D. Smith, MD, at the 2015 San Antonio Breast Cancer Symposium.
“For women who wish to preserve a breast mound, lumpectomy plus whole breast irradiation appears to be a high-value treatment for younger women, and either lumpectomy alone or lumpectomy plus whole breast irradiation appears to be high-value treatments for older women,” he said.
The findings are helpful for framing the early trade-offs, within the first 2 years, for patients who opt for mastectomy plus reconstruction vs. lumpectomy plus whole breast irradiation. “I think they can be integrated into giving patients a fuller picture of what to expect with the different treatment options,” said Smith, associate professor and research director of breast radiation oncology, The University of Texas MD Anderson Cancer Center, Houston.
Guideline-concordant local therapy options for women with early stage breast cancer include lumpectomy alone, lumpectomy plus whole breast irradiation, lumpectomy plus brachytherapy, mastectomy alone, and mastectomy with reconstruction. Patients who receive local therapy concordant with guidelines have equivalent survival but these therapies differ significantly in the extent of surgery and radiation delivered.
Notably absent in the determination of best local therapy for women with early breast cancer is the concept of value, said Smith. To improve the understanding of the relative value of local treatment options for early breast cancer, his group compared the complication burden, total cost, complication-related costs, and non-complication-related costs between treatment options in two unique non-overlapping cohorts: 1) a large commercially available database (MarketScan Commercial Claims and Encounters Database), which captures patients <65 years with private insurance at diagnosis, and 2) the SEER-Medicare data source to study patients at least 66 years old at diagnosis.
All claims from diagnosis to 24 months were used to assess cost. Complication-related cost was defined as the sum of all costs that occurred on days a complication was noted in the insurance claims. Non-complication-related cost was defined as the difference between total cost and complication cost, which can be thought of as treatment costs in the absence of complications.
In the MarketScan cohort, representing about 44,000 patients, the most common treatment was lumpectomy plus whole breast irradiation, chosen by 38% of patients. Mastectomy alone and mastectomy plus reconstruction were the next most common options, each representing approximately one fourth of treated patients.
In the SEER-Medicare cohort, which had about 60,000 patients, the most common treatment was also lumpectomy plus whole breast irradiation, chosen by nearly 50%, with the next most common treatment being mastectomy alone.
“When evaluating the outcome of any complication, the treatment group associated with the highest risk of complications was mastectomy plus reconstruction, at 56%, whereas the treatment associated with lowest risk of complications was mastectomy alone, at 25%,” said Smith.
In the SEER-Medicare cohort, mastectomy plus reconstruction was again associated with the highest risk of any complication (69%). The treatment associated with the lowest risk of any complication was lumpectomy alone.
On logistic regression analysis for the outcome of any complication, findings were similar between the two cohorts. “Relative to lumpectomy plus whole breast irradiation, treatment with mastectomy plus reconstruction was associated with a nearly two-fold increased risk of any complication,” he said. “Of note, lumpectomy plus brachytherapy was also associated with a modest increased risk of any complication, ranging from a 36% to 42% increased risk.”
When total cost was evaluated in the MarketScan cohort, mastectomy plus reconstruction was found to be the most expensive treatment, and mastectomy alone was the least expensive treatment. Relative to lumpectomy plus whole breast irradiation, mastectomy plus reconstruction was $23,000 more expensive per patient.
In the SEER-Medicare cohort, the most expensive treatment was lumpectomy plus brachytherapy and the least expensive treatment was lumpectomy alone. Mastectomy plus reconstruction was associated with about a $2,000 increase in cost per patient compared with lumpectomy plus whole breast irradiation.