Study points to costly trend in breast cancer treatment

When Caroline Wetherall of Kentucky was diagnosed with early-stage breast cancer at age 43, her doctors recommended a complete mastectomy.

Stunned by her diagnosis and her doctors’ aggressive recommendation, Wetherall returned to her hometown of Houston seeking a second opinion.

There, she met radiation oncologist Benjamin Smith, M.D., and was immediately relieved to learn her treatment could be limited to lumpectomy – surgery in which only the tumor and some surrounding tissue is removed – and three weeks of radiation.

“Personally, I couldn’t imagine having both of my breasts unnecessarily removed at such a young age if I didn’t have to,” Wetherall says.

Women with early-stage breast cancer have a number of treatment options, including lumpectomy plus whole breast radiation, lumpectomy plus brachytherapy, in which tiny radioactive seeds are implanted to destroy cancer cells, mastectomy alone, mastectomy plus reconstruction, and, in older women, lumpectomy alone.

These therapies offer equal survival profiles, explains Smith, an associate professor of Radiation Oncology, but differ greatly in terms of what patients endure.

“We haven’t had a nuanced understanding of the pros and cons of these different treatment approaches,” says Smith.

That is, until now.

In a study published in the Journal of the National Cancer Institute, Smith and colleagues found that mastectomy followed by reconstruction had the highest rate of complications and complication-related costs for women with early-stage disease, regardless of their age.

“There’s been little data to understand the differences in complications, and even less data to understand the difference in cost between those options,” says Smith. “Quantifying this information is helpful both for patients making treatment decisions and for payers.”

The rate of mastectomy plus reconstruction has continued to rise across the country over the past decade as reconstruction has become more widely accessible. This study is the first to quantify the harm associated with this trend,
Smith points out.

In conducting the study, researchers analyzed data from more than 100,000 early-stage breast cancer patients who were split into two age groups – younger than 65 and 66 and older. Data was collected from Medicare and other insurance claim databases.

In both age groups, the risk of complications in patients undergoing mastectomy and reconstruction was almost twice that of patients undergoing lumpectomy and radiation. The most common problems were infections, fluid buildup, breast pain, blood clots, implant removal or graft failure.

Mastectomy and reconstruction was the most expensive therapy. The total cost within two years of diagnosis in the younger population was about $88,000, which was $22,000 more expensive than lumpectomy followed by radiation. In the older population, lumpectomy with brachytherapy was most expensive, at approximately $38,000. Mastectomy and reconstruction was around $36,000, while lumpectomy with radiation was $34,000.

Smith says he found the results shocking, especially the fact that, on average, insurance companies pay roughly $10,000 in the two years following diagnosis to deal with complications experienced by patients who chose mastectomy and reconstruction.

“For the first time, we show that while the patient is undergoing more surgery, she is also taking on a considerable amount of risk with regard to what could happen,” Smith says. “If the patient can have a lumpectomy and radiation, it may be a smoother course than going through a mastectomy, reconstruction and, potentially, other surgeries.”

He stresses decisions shouldn’t be based solely on cost, but instead on what’s personally best for each patient.

“Many women with early-stage breast cancer differ in their family histories, genetic profiles and experiences and situations,” he says.

Wetherall says she’s relieved to have been offered lumpectomy with radiation.

“The ‘less-is-more’ option was the right decision for me.”