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Benjamin D. Smith; Jing Jiang; Ya-ChenTina Shih; Sharon H. Giordano; Jinhai Huo; Reshma Jagsi; Adeyiza O. Momoh; Abigail S. Caudle; Kelly K. Hunt; Simona F. Shaitelman; Thomas A. Buchholz; Shervin M. Shirvani DISCLOSURES J Natl Cancer Inst. 2016;109(1)

Abstract and Introduction

Background: Guideline-concordant local therapy options for early breast cancer include lumpectomy plus whole breast irradiation (Lump+WBI), lumpectomy plus brachytherapy, mastectomy alone, mastectomy plus reconstruction, and, in older women, lumpectomy alone. We performed a comparative examination of each treatment’s complications and cost to assess their relative values.
Methods: Using the MarketScan database of younger women with private insurance and the SEER-Medicare database of older women with public insurance, we identified 105 211 women with early breast cancer diagnosed between 2000 and 2011. We used diagnosis and procedural codes to identify treatment complications within 24 months of diagnosis and compared complications by treatment using two-sided logistic regression. Mean total and complication-related cost, relative to Lump+WBI, were calculated from a payer’s perspective and adjusted for differences in covariables using linear regression. All statistical tests were two-sided.
Results: Lump+WBI was the most commonly used treatment. Mastectomy plus reconstruction was associated with nearly twice the complication risk of Lump+WBI (Marketscan: 54.3% vs 29.6%, relative risk [RR] = 1.87, 95% confidence interval [CI] = 1.82 to 1.91, P < .001; SEER-Medicare: 66.1% vs 37.6%, RR = 1.75, 95% CI = 1.69 to 1.82, P < .001) and was also associated with higher adjusted total cost (Marketscan: $22 481 greater than Lump+WBI; SEER-Medicare: $1748 greater) and complication-related cost (Marketscan: $9017 greater; SEER-Medicare: $2092 greater). Brachytherapy had modestly higher total cost and complications than WBI. Lumpectomy alone entailed lower cost and complications in the SEER-Medicare cohort only.
Conclusions: Mastectomy plus reconstruction results in substantially higher complications and cost than other guideline-concordant treatment options for early breast cancer. These findings are relevant to patients evaluating their local therapy options and to value-based population health management.
Achieving value for patients, defined as the quality of outcomes per dollar spent, has captured the attention of health care policy makers as a way to improve care and reduce costs across whole populations.[1,2] The case for value-based care is especially compelling in oncology, where both underuse of effective and inexpensive therapies and overuse of costly but equally effective or marginally better interventions are prevalent.[1,3] Likewise, breast cancer is a cogent target within oncology as it now accounts for the highest number of new cancer cases in the United States and requires substantial societal resources for care of those diagnosed with the disease.[4] Of the nearly 250 000 breast cancer patients diagnosed this year,[4] over 60% will present with localized, early-stage disease[5] for which the National Comprehensive Cancer Network (NCCN) Guidelines identify several evidence-based local management options including mastectomy (Mast alone), mastectomy plus reconstruction (Mast+Recon), lumpectomy plus whole breast irradiation (Lump+WBI), and, in certain cases, lumpectomy plus brachytherapy (Lump+Brachy) or lumpectomy followed by endocrine therapy alone without radiation (Lump alone).[6]

Evidence suggests that real-world decision-making among these options is currently driven by patient and provider preferences, geography, and accessibility to certain treatments.[7–10] Incorporating the risk of complications, cost, and considerations of value into the clinical decision may be a more rational approach to ensuring affordable, effective care for this broad and diverse patient population. Because the local treatment options above are associated with similar survival, their costs, complications, and quality of life implications underpin the value calculation.[11,12] And yet, little research has sought to quantify and compare the expense and toxicities of these therapies in contemporary practice. To address this gap in knowledge, we compared the costs and complications associated with each local strategy using two complementary databases consisting of younger women with private insurance (MarketScan) and older women with public insurance (SEER-Medicare) diagnosed with breast cancer between 2000 and 2011.

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