Cost-Effectiveness Analysis of Breast Reconstruction Options in the Setting of Postmastectomy Radiotherapy Using the BREAST-Q

Abstract

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.

Direct-to-Implant versus Two-Stage Tissue Expander/Implant Reconstruction: 2-Year Risks and Patient-Reported Outcomes from a Prospective, Multicenter Study

“…However, use of direct-to-implant reconstruction remains limited, in part, because of concerns over complication rates. 1,2 The authors’ aim was to compare 2-year complications and patient-reported outcomes for direct-to-implant versus tissue expander/implant reconstruction. …”

“…1 Implant-based reconstruction is the most common method of postmastectomy breast reconstruction in use today. 2 Reconstructive surgeons traditionally use tissue expander/implant reconstruction with or without acellular dermal matrix and a second, later operation, for refinement of the breast pocket and implant placement. However, an alternative option is immediate placement of the implant at the time of mastectomy, referred to as direct-to-implant reconstruction.…”

International multidisciplinary expert panel consensus on breast reconstruction and radiotherapy

“…The generic reference to ‘breast reconstruction’ was intended to capture all articles addressing the type and timing of breast reconstruction. Two authors independently reviewed abstracts of all studies published between 1985 and 2014, and the full texts of those studies published in 2015–2017. Levels of clinical evidence (LoE) were evaluated for each publication and scored from I to V by employing Oxford criteria.…”

Cost‐effectiveness of the BRECONDA decision aid for women with breast cancer: Results from a randomized controlled trial

“…(Mastectomy with immediate breast reconstruction cost US$52 091—mastectomy alone cost US$22 334)/(mastectomy with delayed breast reconstruction cost US$92 988) = 42.12%…”