Skip to main content

Advertisement

SpringerLink
Log in

Cost-effectiveness Analysis of Contralateral Prophylactic Mastectomy Compared to Unilateral Mastectomy with Routine Surveillance for Unilateral, Sporadic Breast Cancer

  • Breast Oncology
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

Contralateral prophylactic mastectomy (CPM) rates in younger women with unilateral breast cancer have more than doubled. Studies of cost and quality of life of the procedure remain inconclusive.

Methods

A cost-effectiveness analysis using a decision-tree model in TreeAge Pro 2015 was used to compare long-term costs and quality of life following unilateral mastectomy (UM) with routine surveillance versus CPM for sporadic breast cancer in women aged 45 years. A 10-year risk period for contralateral breast cancer (CBC), reconstruction, wound complications, cost of routine surveillance, and treatment for CBC were used to estimate accrued costs. In addition, a societal perspective was used to estimate quality-adjusted life years (QALYs) following either treatment for a period of 30 years. Medical costs were obtained from the 2014 Medicare physician fee schedule and event probabilities were taken from recent literature.

Results

The mean cost of UM with surveillance was $14,141 and CPM was $20,319. Treatment with CPM resulted in $6178 more in costs but equivalent QALYs (17.93) compared with UM over 30 years of follow-up. Even with worst-case scenario and varying assumptions, CPM is dominated by UM in terms of cost and quality.

Conclusions

From this refined model, UM with routine surveillance costs less and provides an equivalent quality of life. Patients undergoing CPM may eliminate the anxiety of routine surveillance, but they face the burden of higher lifetime medical costs.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Nichols HB, Berrington de Gonzalez A, Lacey JV Jr, Rosenberg PS, Anderson WF. Declining incidence of contralateral breast cancer in the United States from 1975 to 2006. J Clin Oncol. 2011;29(12):1564–9.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Arrington AK, Jarosek SL, Virnig BA, Habermann EB, Tuttle TM. Patient and surgeon characteristics associated with increased use of contralateral prophylactic mastectomy in patients with breast cancer. Ann Surg Oncol. 2009;16(10):2697–704.

    Article  PubMed  Google Scholar 

  3. Pesce CE, Liederbach E, Czechura T, Winchester DJ, Yao K. Changing surgical trends in young patients with early stage breast cancer, 2003 to 2010: a report from the National Cancer Data Base. J Am Coll Surg. 2014;219(1):19–28.

    Article  PubMed  Google Scholar 

  4. Wong SM, Freedman RA, Sagara Y, Aydogan F, Barry WT, Golshan M. Growing use of contralateral prophylactic mastectomy despite no improvement in long-term survival for invasive breast cancer. Ann Surg. 2016. doi:10.1097/SLA.0000000000001698.

    Google Scholar 

  5. Dragun AE, Pan J, Riley EC, et al. Increasing use of elective mastectomy and contralateral prophylactic surgery among breast conservation candidates: a 14-year report from a comprehensive cancer center. Am J Clin Oncol. 2013;36(4):375–80.

    Article  PubMed  Google Scholar 

  6. Abbott A, Rueth N, Pappas-Varco S, Kuntz K, Kerr E, Tuttle T. Perceptions of contralateral breast cancer: an overestimation of risk. Ann Surg Oncol. 2011;18(11):3129–36.

    Article  PubMed  Google Scholar 

  7. Covelli AM, Baxter NN, Fitch MI, McCready DR, Wright FC. ‘Taking control of cancer’: understanding women’s choice for mastectomy. Ann Surg Oncol. 2015;22(2):383–91.

    Article  PubMed  Google Scholar 

  8. Rosenberg SM, Tracy MS, Meyer ME, et al. Perceptions, knowledge, and satisfaction with contralateral prophylactic mastectomy among young women with breast cancer: a cross-sectional survey. Ann Intern Med. 2013;159(6):373–81.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Parker PA, Peterson SK, Bedrosian I, et al. Prospective study of surgical decision-making processes for contralateral prophylactic mastectomy in women with breast cancer. Ann Surg. 2016;263(1):178–83.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Tuttle TM, Habermann EB, Grund EH, Morris TJ, Virnig BA. Increasing use of contralateral prophylactic mastectomy for breast cancer patients: a trend toward more aggressive surgical treatment. J Clin Oncol. 2007;25(33):5203–9.

    Article  PubMed  Google Scholar 

  11. Koslow S, Pharmer LA, Scott AM, et al. Long-term patient-reported satisfaction after contralateral prophylactic mastectomy and implant reconstruction. Ann Surg Oncol. 2013;20(11):3422–9.

    Article  PubMed  Google Scholar 

  12. Kurian AW, Lichtensztajn DY, Keegan TH, Nelson DO, Clarke CA, Gomez SL. Use of and mortality after bilateral mastectomy compared with other surgical treatments for breast cancer in California, 1998–2011. JAMA. 2014;312(9):902–14.

    Article  CAS  PubMed  Google Scholar 

  13. Deshmukh AA, Cantor SB, Crosby MA, et al. Cost of contralateral prophylactic mastectomy. Ann Surg Oncol. 2014;21(9):2823–30.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Zendejas B, Moriarty JP, O’Byrne J, Degnim AC, Farley DR, Boughey JC. Cost-effectiveness of contralateral prophylactic mastectomy versus routine surveillance in patients with unilateral breast cancer. J Clin Oncol. 2011;29(22):2993–3000.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Roberts A, Habibi M, Frick KD. Cost-effectiveness of contralateral prophylactic mastectomy for prevention of contralateral breast cancer. Ann Surg Oncol. 2014;21(7):2209–17.

    Article  PubMed  Google Scholar 

  16. Lester-Coll NH, Lee JM, Gogineni K, Hwang WT, Schwartz JS, Prosnitz RG. Benefits and risks of contralateral prophylactic mastectomy in women undergoing treatment for sporadic unilateral breast cancer: a decision analysis. Breast Cancer Res Treat. 2015;152(1):217–26.

    Article  PubMed  Google Scholar 

  17. Yao K, Sisco M, Bedrosian I. Contralateral prophylactic mastectomy: current perspectives. Int J Women’s Health. 2016;8:213–23.

    Article  Google Scholar 

  18. Grimmer 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):187–96.

    Article  PubMed  Google Scholar 

  19. Kruper L, Kauffmann RM, Smith DD, Nelson RA. Survival analysis of contralateral prophylactic mastectomy: a question of selection bias. Ann Surg Oncol. 2014;21(11):3448–56.

    Article  PubMed  Google Scholar 

  20. Boughey JC, Attai DJ, Chen SL, et al. Contralateral prophylactic mastectomy (CPM) Consensus Statement from the American Society of Breast Surgeons: data on CPM outcomes and risks. Ann Surg Oncol. 2016;23(10):3100–5.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Tuttle TM, Barrio AV, Klimberg VS, et al. Guidelines for guidelines: an assessment of the American Society of Breast Surgeons Contralateral Prophylactic Mastectomy Consensus Statement. Ann Surg Oncol. 2016. doi:10.1245/s10434-016-5648-7.

    Google Scholar 

  22. TreeAge Pro 2015, R1.0. Williamstown, MA: TreeAge Software. p. software. https://www.treeage.com.

  23. Institute NC. NCI dictionary of cancer terms: early-stage breast cancer. http://www.cancer.gov/publications/dictionaries/cancer-terms?cdrid=446564. Accessed 11 June 2015.

  24. Albornoz CR, Bach PB, Mehrara BJ, et al. A paradigm shift in U.S. Breast reconstruction: increasing implant rates. Plast Reconstr Surg. 2013;131(1):15–23.

    Article  CAS  PubMed  Google Scholar 

  25. Giacalone PL, Bricout N, Dantas MJ, Daures JP, Laffargue F. Achieving symmetry in unilateral breast reconstruction: 17 years experience with 683 patients. Aesthetic Plast Surg. 2002;26(4):299–302.

    Article  PubMed  Google Scholar 

  26. Losken A, Carlson GW, Bostwick J, 3rd, Jones GE, Culbertson JH, Schoemann M. Trends in unilateral breast reconstruction and management of the contralateral breast: the Emory experience. Plast Reconstr Surg. 2002;110(1):89–97.

    Article  PubMed  Google Scholar 

  27. 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):3212–7.

    Article  PubMed  Google Scholar 

  28. Saha D, Davila AA, Ver Halen JP, et al. Post-mastectomy reconstruction: a risk-stratified comparative analysis of outcomes. Breast. 2013;22(6):1072–80.

    Article  PubMed  Google Scholar 

  29. Antony AK, McCarthy C, Disa JJ, Mehrara BJ. Bilateral implant breast reconstruction: outcomes, predictors, and matched cohort analysis in 730 2-stage breast reconstructions over 10 years. Ann Plast Surg. 2014;72(6):625–30.

    Article  CAS  PubMed  Google Scholar 

  30. Butz DR, Lapin B, Yao K, et al. Advanced age is a predictor of 30-day complications after autologous but not implant-based postmastectomy breast reconstruction. Plast Reconstr Surg. 2015;135(2):253e–61e.

    Article  CAS  PubMed  Google Scholar 

  31. Portschy PR, Kuntz KM, Tuttle TM. Survival outcomes after contralateral prophylactic mastectomy: a decision analysis. J Natl Cancer Inst. 2014. doi:10.1093/jnci/dju160.

    PubMed  Google Scholar 

  32. Quan G, Pommier SJ, Pommier RF. Incidence and outcomes of contralateral breast cancers. Am J Surg. 2008;195(5):645–50; discussion 50.

    Article  PubMed  Google Scholar 

  33. Peasgood T, Ward S, Brazier J. A review and meta-analysis of health state utility values in breast cancer. 2010.

  34. Oestreicher N, Ramsey SD, Linden HM, et al. Gene expression profiling and breast cancer care: what are the potential benefits and policy implications? Genet Med. 2005;7(6):380–9.

    Article  PubMed  Google Scholar 

  35. Ko CY, Maggard M, Livingston EH. Evaluating health utility in patients with melanoma, breast cancer, colon cancer, and lung cancer: a nationwide, population-based assessment. J Surg Res. 2003;114(1):1–5.

    Article  PubMed  Google Scholar 

  36. Statistics BoL. CPI Inflation Calculator. 2015.

  37. Services CfMM. Physician Fee Schedule Search. http://www.cms.gov/apps/physician-fee-schedule/overview.aspx. Accessed 7 June 2015.

  38. Services USDoHH. H-CUPnet an online query system based on data from the Healthcare Cost and Utilization Project. http://hcupnet.ahrq.gov/HCUPnet.jsp. Accessed 11 June 2015.

  39. Foundation HJKF. Hospital adjusted expenses per inpatient day. http://kff.org/other/state-indicator/expenses-per-inpatient-day/. Accessed 11 June 2015.

  40. Khatcheressian JL, Hurley P, Bantug E, et al. Breast cancer follow-up and management after primary treatment: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol. 2013;31(7):961–5.

    Article  CAS  PubMed  Google Scholar 

  41. Schootman M, Fuortes L, Aft R. Prognosis of metachronous contralateral breast cancer according to stage at diagnosis: the importance of early detection. Breast Cancer Res Treat. 2006;99(1):91–5.

    Article  PubMed  Google Scholar 

  42. Moja L, Tagliabue L, Balduzzi S, et al. Trastuzumab containing regimens for early breast cancer. Cochrane Database Syst Rev. 2012;4:CD006243.

  43. Edejer TT-T, World Health Organization. Making choices in health: WHO guide to cost-effectiveness analysis. Geneva: World Health Organization; 2003.

  44. Crosby MA, Garvey PB, Selber JC, et al. Reconstructive outcomes in patients undergoing contralateral prophylactic mastectomy. Plast Reconstr Surg. 2011;128(5):1025–33.

    Article  CAS  PubMed  Google Scholar 

  45. Murphy JA, Milner TD, O’Donoghue JM. Contralateral risk-reducing mastectomy in sporadic breast cancer. Lancet Oncol. 2013;14(7):e262–9.

    Article  PubMed  Google Scholar 

  46. Briggs A, Fenn P. Confidence intervals or surfaces? Uncertainty on the cost-effectiveness plane. Health Econ. 1998;7(8):723–40.

    Article  CAS  PubMed  Google Scholar 

  47. Razdan SN, Patel V, Jewell S, McCarthy CM. Quality of life among patients after bilateral prophylactic mastectomy: a systematic review of patient-reported outcomes. Qual Life Res. 2016;25:1409–1421.

    Article  PubMed  Google Scholar 

  48. Paik S, Tang G, Shak S, et al. Gene expression and benefit of chemotherapy in women with node-negative, estrogen receptor-positive breast cancer. J Clin Oncol. 2006;24(23):3726–34.

    Article  CAS  PubMed  Google Scholar 

  49. Murphy CC, Bartholomew LK, Carpentier MY, Bluethmann SM, Vernon SW. Adherence to adjuvant hormonal therapy among breast cancer survivors in clinical practice: a systematic review. Breast Cancer Res Treat. 2012;134(2):459–78.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. The Hiram C. Polk Jr. MD Department of Surgery, University of Louisville School of Medicine, Louisville, KY, USA

    Robert C. Keskey MD, William G. Cheadle MD, FACS, Kelly M. McMasters MD, PhD, FACS & Nicolas Ajkay MD, FACS

  2. University of Louisville School of Public Health and Information Sciences, Louisville, KY, USA

    A. Scott LaJoie PhD

  3. Department of Medicine, Cardiovascular Medicine, University of Louisville School of Medicine, Louisville, KY, USA

    Brad S. Sutton MD, MBA

  4. Center for Health Process Innovation, University of Louisville, Louisville, KY, USA

    Brad S. Sutton MD, MBA & In K. Kim MD, MBA

  5. Department of Pediatrics, Emergency Medicine, University of Louisville School of Medicine, Louisville, KY, USA

    In K. Kim MD, MBA

  6. Department of Surgery, University of Chicago, Chicago, IL, USA

    Robert C. Keskey MD

Authors
  1. Robert C. Keskey MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. A. Scott LaJoie PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Brad S. Sutton MD, MBA
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. In K. Kim MD, MBA
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. William G. Cheadle MD, FACS
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Kelly M. McMasters MD, PhD, FACS
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Nicolas Ajkay MD, FACS
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Nicolas Ajkay MD, FACS.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Keskey, R.C., LaJoie, A.S., Sutton, B.S. et al. Cost-effectiveness Analysis of Contralateral Prophylactic Mastectomy Compared to Unilateral Mastectomy with Routine Surveillance for Unilateral, Sporadic Breast Cancer. Ann Surg Oncol 24, 3903–3910 (2017). https://doi.org/10.1245/s10434-017-6094-x

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1245/s10434-017-6094-x

Keywords

Search

Navigation