SAN ANTONIO -- Among the various guideline-concordant local therapy options available for women with early-stage breast cancer in the United States, mastectomy plus reconstruction had the highest complication rates and complication-related costs for both younger women with private insurance and older women on Medicare, and it was the most expensive option for younger women, according to data presented at the 2015 San Antonio Breast Cancer Symposium, held Dec. 8-12.
"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," said Benjamin D. Smith, MD, associate professor and research director of the breast radiation oncology section in the Department of Radiation Oncology at The University of Texas MD Anderson Cancer Center in Houston.
Current guideline-concordant local therapy options for women with early-stage breast cancer include lumpectomy plus whole breast irradiation (lump+WBI), lumpectomy plus brachytherapy (lump+brachy), mastectomy without reconstruction or radiation (mast alone), mastectomy with reconstruction without radiation (mast+recon), and lumpectomy without radiation (lump alone).
"We really don't have a good framework to help patients understand what the experience with mastectomy and reconstruction will be, compared with lumpectomy and whole-breast irradiation, and what the trade-offs are between these different treatments with regard to side effects, cost to the patient, and the cost to their insurance company. To me, it seemed like a black box," Smith added.
"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," Smith said.
Smith and colleagues used two data sources to gather information on treatment costs: the MarketScan database, a commercially available database on insurance claims from employers that they used to gather data on younger women, and the SEER-Medicare database, which they used to collect data on older women.
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. Complications from therapy within two years of diagnosis, including wound, local infection, seroma or hematoma, fat necrosis, breast pain, pneumonitis, rib fracture, graft failure, and implant removal, were identified using diagnosis and procedure codes, and complication-related costs and total costs were calculated.
Based on data gathered from 44,344 patients from the MarketScan cohort, the risk of complications for younger women were: 30 percent for lump+WBI, 45 percent for lump+brachy, 25 percent for mast alone, and 56 percent for mast+recon.
For older women from the SEER-Medicare cohort of 60,867 patients, the risk of complications were: 38 percent for lump+WBI, 51 percent for lump+brachy, 37 percent for mast alone, 69 percent for mast+recon, and 31 percent for lump alone.
Risk of complications from mast+recon was two times higher than lump+WBI for both younger and older women, after adjusting for other differences in patients and how they were treated.
Complication-related costs were $8,608 higher with mast+recon than lump+WBI for younger women with private insurance and $2,568 higher for older women with Medicare.
The most expensive therapy (procedure cost plus complication costs) for younger women was mast+recon, with an average cost of $89,140, which was $23,421 more than lump+WBI. For Medicare patients, lump+brachy and mast+recon were the two most expensive therapies, costing $37,741 and $36,166, respectively, while the cost of lump+WBI was $34,097.
"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. "Our study findings are also particularly relevant from a payer's perspective, given the growing emphasis placed on promoting treatments that are effective, safe, and cost-conscious."
This study was supported by grants from the Department of Health Services, Varian Medical Systems, and the Duncan Family Foundation. Smith declares no conflicts of interest.
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Title: Complication and economic burden of local therapy options for early breast cancer
Authors: Benjamin D Smith1, Jing Jiang1, Ya-Chen Tina Shih1, Sharon H Giordano1, Jinhai Huo1, Reshma Jagsi2, Abigail S Caudle1, Kelly K Hunt1, Simona F Shaitelman1, Thomas A Buchholz1, and Shervin M Shirvani3.
Institutions: 1The University of Texas MD Anderson Cancer Center, Houston, TX, United States, 77030; 2The University of Michigan, Ann Arbor, MI, United States and 3Banner MD Anderson Cancer Center, Gilbert, AZ, United States.
Background: Guideline-concordant local therapy options for early breast cancer include lumpectomy plus whole breast irradiation (lump+WBI), lumpectomy plus brachytherapy (lump+brachy), mastectomy without reconstruction or radiation (mast alone), mastectomy with reconstruction without radiation (mast+recon), and, in older women, lumpectomy without radiation (lump alone). Little is known regarding the comparative complication and economic burden of these options in the general population.
Methods: We used the MarketScan database which includes younger women with private insurance and the SEER-Medicare database which includes older women with Medicare. Women were included if they had early stage disease (T1/2 N0/1 M0) diagnosed in 2000-2011, no prior cancer, and complete insurance coverage from 12 months prior through 24 months after diagnosis. A complication from local therapy was defined as a diagnosis or procedure code for any of the following within 24 months of diagnosis: wound complication, local infection, seroma/hematoma, fat necrosis, breast pain, pneumonitis, rib fracture, implant removal, and graft failure. Total costs and complication-related costs within 24 months of diagnosis were calculated from a payer's perspective and are reported in 2014 dollars. Logistic regression compared complications by local therapy and generalized linear regression (log link function, gamma distribution) compared complication-related and total costs by local therapy; all models adjusted for relevant covariables.
Results: We selected 44,344 patients from the MarketScan cohort, median age of 53, and 60,867 patients from the SEER-Medicare cohort, median age of 75. For the MarketScan cohort, risk of complications varied as follows: 30% risk in patients treated with lump+WBI (referent), 45% with lump+brachy (adjusted risk ratio [ARR]=1.46;P<.001), 25% with mast alone (ARR=0.88;P<.001), and 56% with mast+recon (ARR=1.94;P<.001). For the SEER-Medicare cohort, risk of complications varied as follows: 38% with lump+WBI (referent), 51% with lump+brachy (ARR=1.36;P<.001), 37% with mast alone (ARR=0.98;P=.08), 69% with mast+recon (ARR=1.82; P<.001), and 31% with lump alone (AOR=0.87; P<.001). Compared to lump+WBI, mean adjusted complication-related cost was $8,608 higher per patient with mast+recon in the MarketScan cohort and $2,568 higher per patient with mast+recon in the SEER-Medicare cohort. In contrast, complication-related costs were similar (+/- $517) for all other local therapy options relative to lump+WBI in both cohorts. For total cost, mast+recon was the most expensive local therapy in the MarketScan cohort, with mean adjusted total cost of $89,140, which was $23,421 more expensive than lump+WBI. In the SEER-Medicare cohort, lump+brachy was the most expensive option ($37,741), followed by mast+recon ($36,166), lump+WBI ($34,097), mast alone ($22,424), and lump alone ($21,154).
Conclusion: Mast+recon results in the highest complication rate and complication-related cost in both younger women and older women with early breast cancer. These findings are relevant to defining which local therapies offer the highest value to patients, payers, and society, and are relevant to patients when evaluating their local therapy options.
This research will be presented at a press conference at the 2015 San Antonio Breast Cancer Symposium, moderated by SABCS Co-director and AACR Past-president Carlos L. Arteaga, MD, director of the Breast Cancer Program at Vanderbilt-Ingram Cancer Center, Thursday, Dec. 10, 7:30 a.m. CT in Room 217D of the Henry B. Gonzalez Convention Center. Reporters who cannot attend the press conference in person can call in using the following information:
- United States/Canada (toll-free): 866-297-6395
- International (toll): 1-847-944-7317
- Conference code number: 41320576
To interview Benjamin Smith, contact Julia Gunther at email@example.com or 267-250-5441.