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Prophylactic Mastectomies: Implications of Occult Histology and Lifetime Cost of Surveillance vs. Surgery
David Mattos, A.B.1, Richard G. Reish, M.D.2, Curtis Cetrulo, MD2, Amy S. Colwell, MD2, Jonathan M. Winograd, MD2, Michael J. Yaremchuk, MD2, William G. Austen, Jr., M.D.2, Eric C. Liao, M.D., Ph.D.2.
1Harvard Medical School, Boston, MA, USA, 2Massachusetts General Hospital, Boston, MA, USA.
During the last decade, our institution saw a 260% increase in bilateral breast reconstruction cases, consistent with national trends, and recently highlighted in the press with the bilateral elective mastectomy of a Hollywood actress.1 We reported a drop in average age of prophylactic mastectomy from 57 to 51 years. There is limited data on the likelihood of histological abnormalities in this population. This study measures the prevalence of occult histological findings in prophylactic mastectomy patients. Given the current healthcare reform climate, we estimate the lifetime cost implications of prophylactic mastectomy with single-stage reconstruction vs. surveillance.
A retrospective database of breast reconstructions at our institution was searched from 2004 to 2011 for prophylactic mastectomy patients. Breasts with prior biopsy-proven LCIS, DCIS, or cancer were excluded. Patient demographics, risk factors, and pathology reports were collected. Lifetime treatment costs were estimated with 2013 rates from the Center for Medicare and Medicaid Services using Current Procedural Terminology and Diagnosis Related Group codes. Costs were estimated for two groups: 45 year old patients undergoing contralateral or bilateral prophylactic mastectomies versus surveillance. Conversion rates to cancer in these patients were used to estimate the percentage patients in the surveillance group that would need surgery.
436 patients were identified that had a prophylactic mastectomy on at least one breast, of which 10 patients (2.0%) had invasive cancer, 22 (5%) had DCIS, 51 (11.7%) had LCIS, and 97 (22.2%) had atypia as the highest-risk lesion, a total of 180 (41.3%) patients. The likelihood of finding LCIS, DCIS, or cancer increased with age (P < 0.001). LCIS, DCIS, or invasive cancer was found in 12.3% of BRCA patients and 21.9% of non-BRCA patients (P=0.02). The percentage of patients with LCIS, DCIS, or invasive cancer was 16.9% in the bilateral group vs. 19.4% in the contralateral group (P=0.66). Lifetime costs for bilateral prophylactic mastectomies were estimated to be $48,118, lower than the $55,165 necessary for bilateral surveillance. For patients with one-sided cancer, contralateral mastectomy would add $1,702 whereas surveillance would add $26,080.
Prophylactic mastectomy patients have a significant rate of occult histological findings, increasing with age. Unexpectedly, BRCA patients had a lower prevalence of findings, despite higher lifetime risk of breast cancer. Lifetime cost estimates suggest a cost-saving role in bilateral and contralateral prophylactic mastectomies. Ultimately, such a critical decision needs to be made individually, but should not be hindered by cost concerns. This pioneering study addresses a gap in knowledge with broad interest, contributing evidence of oncologic risk and cost to help guide decision-making in prophylactic mastectomy.
1. Fitzpatrick AM, Gao LL, Smith BL, et al. Cost and Outcome Analysis of Breast Reconstruction Paradigm Shift. Annals of plastic surgery. 2013; Epub ahead of print.
|Table 1: Patients with LCIS, DCIS, or Invasive Cancer/Group size (% with findings)|
|Age||≤ 29||0/5 (0%)||0/1 (0%)||0/6 (0%)|
| ||30-39||3/87 (3%)||3/17 (18%)||6/104 (6%)|
| ||40-49||40/189 (21%)||3/26 (12%)||43/215 (20%)|
| ||50-59||24/79 (30%)||3/14 (21%)||27/93 (29%)|
| ||≥60||6/17 (35%)||1/1 (100%)||7/18 (39%)|
| ||Total||73/377 (19%)||10/59 (17%)||83/436 (19%)|
|BRCA||Positive||9/81 (11%)||7/49 (14%)||16/130 (12%)|
| ||Negative||64/296 (22%)||3/10 (30%)||67/306 (22%)|
|FH||Yes||54/276 (20%)||10/57 (18%)||64/333 (19%)|
| ||No||19/101 (19%)||0/2 (0%)||19/103 (18%)|
|Prior BSO ||Yes||6/44 (14%)||2/30 (7%)||8/74 (11%)|
| ||No||67/333 (20%)||8/29 (28%)||75/362 (21%)|
|BMI||<30||62/334 (19%)||9/53 (17%)||71/387 (18%)|
| ||≥30||11/43 (26%)||1/6 (17%)||12/49 (25%)|
|Smoke||Yes||12/50 (24%)||3/9 (33%)||15/59 (25%)|
| ||No||61/327 (19%)||7/50 (14%)||68/377 (18%)|
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