Unilateral Mastectomy Is a More Cost-Effective Treatment for Sporadic Cancer in One Breast Than Contralateral Prophylactic Mastectomy
For younger women with early-stage, noninherited breast cancer on one side, a unilateral mastectomy leads to a slightly higher quality of life and lower costs over the next 20 years compared with contralateral prophylactic mastectomy, 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 sporadic breast cancer.
Increasing Rates of Contralateral Prophylactic Mastectomy
American women with unilateral breast cancer are increasingly choosing contralateral prophylactic mastectomy. One study by Grimm et al reported that the contralateral prophylactic mastectomy rate increased from 1.9% in 1998 to 10.2% in 2011. However, according to NCCN Guidelines, there is no strong evidence that prophylactic mastectomy improves survival for women with sporadic breast cancer, and a study by Osman et al proved that double mastectomy poses nearly double the risk of postoperative complications.
Researchers led by Nicolas Ajkay, MD, FACS, Assistant Professor of Surgery at the University of Louisville School of Medicine, 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, 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 contralateral prophylactic mastectomy.”
Cost-Analysis Results
Single mastectomy plus 20 years of routine mammograms on the remaining breast costs, on average, $5,052 less than contralateral prophylactic mastectomy ($13,525 vs $18,577), the research team reported. In estimating costs, the investigators took into account physician and imaging fees, hospitalization, 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 5 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), 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 vs 14.54 QALYs), which Dr. Ajkay said equates to approximately 3 months of improved health and quality of life.
For a woman who chooses contralateral prophylactic mastectomy, a QALY loss of 0.21, according to Dr. Ajkay, could mean, “about 3 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 contralateral prophylactic mastectomy, 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 contralateral prophylactic mastectomy, 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 contralateral prophylactic mastectomy, and the QALY was 0.20 better than that with contralateral prophylactic mastectomy.
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 contralateral prophylactic mastectomy.”
The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.
