DIEP flaps are cost-effective compared with implants, especially for unilateral reconstructions. Cost-effectiveness of autologous techniques is maximized in women with longer life expectancy. Patient-reported outcomes findings can be incorporated into cost-effectiveness analyses to demonstrate the relative value of reconstructive procedures.
Background
A consensus is lacking on a uniform reconstructive algorithm for patients with locally advanced breast cancer who require postmastectomy radiotherapy (PMRT). Both delayed autologous and immediate prosthetic techniques have inherent advantages and complications. The study hypothesis is that implants are more cost-effective than autologous reconstruction in the setting of PMRT because of immediate restoration of the breast mound.
Methods
A cost-effectiveness analysis model using the payer perspective was created comparing delayed autologous and immediate prosthetic techniques against the do-nothing option of mastectomy without reconstruction. Costs were obtained from Nationwide Inpatient Sample 2010 database. Effectiveness was determined using the BREAST-Q patient reported outcome measure. A Breast-QALY was considered one year of perfect breast health related quality of life. Incremental cost-effectiveness ratio (ICER) was calculated for both treatments compared to the do-nothing option.
Results
BREAST-Q scores were obtained from patients who underwent immediate prosthetic reconstruction (n=196), delayed autologous reconstruction (n=76) and mastectomy alone (n=71). The ICER for immediate prosthetic and delayed autologous reconstruction compared to mastectomy alone was $57,906 and $102,509 respectively. Sensitivity analysis showed that the ICER for both treatment options decreased with increasing life expectancy.
Conclusion
For patients with advanced breast cancer who require PMRT, immediate prosthetic based breast reconstruction is a cost-effective approach. Despite high complication rates, implant use can be rationalized based on low cost as well as HRQOL benefit derived from early breast mound restoration. If greater life expectancy is anticipated, autologous transfer is cost-effective as well and may be a superior option.
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