Breast removal risk, cost soaring
MD Anderson study questions popular treatment
U.S. women with early breast cancer are increasingly opting to have their entire breast removed and then reconstructed, but a new Houston study has found the treatment carries a significantly higher price tag and greater risk of major follow-up problems than other options.
MD Anderson Cancer Center researchers reported Tuesday that data from more than 100,000 such patients show those who had a mastectomy and reconstruction were nearly twice as likely to suffer complications than those who had a lumpectomy followed by radiation.
The more extensive treatment costs roughly $88,000 per patient, $23,000 more than the less extensive lumpectomy treatment. More than $9,000 of that cost occurred managing complications.
“This is the first study to quantify the harm associated with the U.S.’s rising mastectomy and reconstruction rates as opposed to simpler options,” said Dr. Benjamin Smith, an MD Anderson professor of radiation oncology and the study’s principle investigator. “The clear takeaway here is that if you’re diagnosed with early-stage breast cancer, lumpectomy
plus radiation is the best complication profile and value.”
Smith said he hopes the study, published in the Journal of the National Cancer Institute, better arms doctors to counsel patients. He said the findings may not come as a great shock to many surgeons, but doubts that many tell patients there is a significantly higher risk of major complications from reconstruction after mastectomy because they haven’t been able to cite statistics. He said he never emphasized the risk to patients.
Dr. Deanna Attai, a UCLA breast surgeon and a past president of the American Society for Breast Surgeons, said that it’s good to have “more pieces of information to give to patients deciding on a treatment, but it remains to be seen whether it sways them.” She suggested the cost data might have the best potential.
“In this insurance climate, patients may notice reconstruction’s higher price tag,” Attai said. ”Historically, cost didn’t really resonate with patients because they knew insurance was covering their treatment. But now that so many have large deductibles, they may be more sensitive to the amount they’re sharing.”
‘Angelina Jolie effect’
Some 140,000 U.S. women are diagnosed annually with early-stage breast cancer, and most are eligible for numerous treatment options, including lumpectomy, usually followed by either of two types of radiation, and mastectomy, with or without reconstruction. Applied appropriately, there are no survival differences from the therapies.
Lumpectomies became popular in the 1990s after studies showed surgery that removed the entire breast while disfiguring the chest didn’t improve survival. But between 2005 and 2013, the number of mastectomies increased 36 percent — double mastectomies more than tripled — according to the federal Agency for Health Research and Quality. Smith estimates that probably half of women under 50 now opt for mastectomy to treat their early breast cancer.
It’s often attributed to “the Angelina Jolie effect,” after the actress who had a preventative double mastectomy upon testing positive for the gene that predisposes carriers to breast and ovarian cancer. Amid the media blitz, women cited fears about possible recurrence, freedom of anxiety about a lifetime of screenings and improved reconstruction.
Smith decided to undertake the study after realizing how little hard data he could give patients choosing between treatment plans. To assess treatment values, he culled data on more than 44,000 women aged 65 years or younger from a private insurance claims database and nearly 61,000 women aged 66 years or older from a Medicare database.
He said he would have hypothesized a higher complication rate among reconstruction patients but was shocked the figure was so high. The findings held true for both younger covered by private insurance and older women on Medicare.
More than half of women who opted for a mastectomy plus reconstruction — 56 percent of younger women and 69 percent of older women — developed complications within two years of their original cancer diagnosis. In contrast, only 31 percent of women in both groups who opted for lumpectomy alone developed complications.
A second opinion
The most common complications were infections, wound problems and buildups of blood or fluid.
It’s not always the patient who pushes for more aggressive treatment. In the case of Caroline Wetherall, 45, it was her oncology team in Cincinnati that urged her to get a double mastectomy and hysterectomy after she had already undergone a lumpectomy for a small Stage 1 tumor.
She came to MD Anderson for a second opinion last fall and was heartened to learn that a gene she’d been told could raise her risk of the breast cancer returning was really a negative factor. Under the MD Anderson team’s treatment plan, she received only follow-up radiation — and remains complication-free a year later.
“I can’t tell you the relief I felt, the tears of joy I shed,” said Wetherall, a nurse. “I’d been in disbelief to have my team recommend such harsh, unnecessary treatment. It was nice that it turned out that my case wasn’t the end of the world, that we were where I thought we were.”