Cost and Complications of Local Therapies for Early-Stage Breast Cancer

Abstract

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.

Figure 1.

Complications by year of diagnosis and local therapy (unadjusted). Unadjusted time trends in risk of any complication by type of local therapy. Data for lumpectomy plus brachytherapy in 2000 and 2001 are not shown for the MarketScan cohort because of small numbers (n = 5). SEER = Surveillance, Epidemiology, and End Results; WBI = whole breast irradiation.

Figure 2.

Adjusted total and complication-related cost relative to lumpectomy and whole breast irradiation for patients diagnosed in 2010 and 2011. Adjusted difference in total cost and complication-related cost of local therapy options, relative to lumpectomy plus whole breast irradiation, for patients diagnosed in 2010 and 2011. SEER = Surveillance, Epidemiology, and End Results; WBI = whole breast irradiation.