A Cost-utility Analysis Comparing Large Volume Displacement Oncoplastic Surgery To Mastectomy With Single Stage Implant Reconstruction In The Treatment Of Breast Cancer
Abhishek Chatterjee, MD,MBA1, Ammar Asban, MD2, Lilian Chen, MD1, Carla Fisher, MD3.
1Tufts Medical Center, Boston, MA, USA, 2University of Alabama, Birmingham, AL, USA, 3University of Pennsylvania, Philadelphia, PA, USA.
For larger cancers in moderate to large breast sized women, breast surgical cancer treatment may include large volume displacement oncoplastic surgery (LVOS) or mastectomy with single stage implant reconstruction (SSIR). Often in the case of LVOS, reduction mammaplasty designs are used in the oncoplastic reconstructions with a contralateral symmetry operation. The goal of this study was to investigate the cost-utility between LVOS versus SSIR to determine which approach is cost-effective in the treatment of breast cancer. There has been no previous cost nor clinical effectiveness analysis comparing these techniques.
A review of the literature was performed to calculate probabilities for clinical outcomes for each surgical option (LVOS versus SSIR), and to obtain utility scores that were converted into quality adjusted life years (QALYs) as measures for clinical effectiveness. For a cost assessment pertaining to outcomes in each surgical option, average national Medicare payment rates using DRG and CPT codes were used. Radiation was assumed as adjuvant treatment in the LVOS arm. A decision analysis tree was constructed comparing LVOS to SSIR (Figure 1) into which these probabilities, QALYs and costs were placed. An incremental cost-utility ratio (ICUR) was calculated comparing the difference for both surgical options in costs by the difference in clinical-effectiveness to see which surgical option was more cost-effective. To validate our results, we performed one-way sensitivity analyses in addition to a Monte-Carlo analysis.
The decision tree (Figure 1) shows the associated probabilities, QALYs and costs for each clinical outcome arising from either the LVOS arm or the SSIR arm. An ICUR of $644/QALY favoring LVOS was calculated based off of its clinical-effectiveness gain of 7.11 QALY at an additional cost of $4,579.43 (partly due to the additional costs of radiation treatment and the bilateral operation needed for LVOS compared to no radiation and unilateral surgery for SSIR). This proved that LVOS is a cost-effective surgical option given that a surgical approach is deemed cost-effective if its ICUR is less than $50,000/QALY. One-way sensitivity analyses underscored the degree by which LVOS was cost-effective. For example, LVOS became cost-ineffective when a successful LVOS cost more than $50,000 (more than twice its estimated cost shown in Figure 1). Similarly, probabilistic sensitivity analysis using Monte-Carlo simulation showed that even with varying multiple variables at once, results tended to favor our conclusion supporting the cost-effectiveness of LVOS.
For the appropriate patients with moderate to large sized breasts with breast cancer, large volume displacement oncoplastic surgery is cost-effective in breast cancer treatment compared to mastectomy with single staged implant reconstruction. This provides yet another reasonable breast conservation surgical option for the breast cancer patient.
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