Elsevier

Surgery

Volume 125, Issue 4, April 1999, Pages 441-447
Surgery

Surgical Outcomes Research
A sociodemographic and economic comparison of breast reconstruction, mastectomy, and conservative surgery

https://doi.org/10.1016/S0039-6060(99)70012-7Get rights and content

Abstract

Background: There are a variety of surgical choices for women with early-stage breast cancer, including breast-conserving surgery, mastectomy, or mastectomy plus reconstructive surgery. This report examines some of the factors that affect these choices and the costs of the various treatment options. Methods: Data from the Virginia Cancer Registry were linked to insurance claims from the Trigon Blue Cross and Blue Shield Company for women with local and regional staged breast cancer from 1989 to 1991 in Virginia. Multivariate analyses and cost studies were performed. Results: There were 592 women who underwent breast-conserving surgery (BCS, 26%), mastectomy (58%), or mastectomy plus reconstruction (16%). Increasing age reduced the use of reconstruction. The choice of reconstruction was not affected by tumor size, nodal status, or race. Sixty percent of women had immediate breast reconstruction at the time of mastectomy; the majority had the implant procedure. The cost of BCS ($21,582) was higher than that of mastectomy ($16,122, P < .01). The costs for BCS and mastectomy were significantly lower than for mastectomy plus reconstruction ($31,047, P < .05). The 2-year cost for immediate reconstruction was $8200 less than for delayed procedures and was similar to the cost of BCS. Conclusions: Age was the driving force in reconstruction decisions. Clinical factors such as tumor size and nodal status were more important for the choice between BCS and mastectomy. There are significant cost differences between the various procedures. For a similar cosmetic outcome, BCS is less expensive than breast reconstruction. When reconstruction is required, a simultaneous procedure is less expensive. (Surgery 1999;125:441-7.)

Section snippets

Data sources

Data for this study were obtained from the Virginia Cancer Registry (VCR) and Trigon Blue Cross Blue Shield of Virginia (Trigon). During the study period (1989 to 1993), the registry collected data from approximately 50 hospitals, representing about 85% of the hospital beds in the state. Over this period Trigon insured approximately 30% of the state population; the penetration by managed care was low at that time. Cancer registry data were collected prospectively by trained registrars with use

Clinical factors

Table 1 shows the demographic and clinical characteristics of the women with breast cancer and the 3 treatment options studied in this report.

. Demographic and clinical characteristics of cohort

CharacteristicsBreast cancer cohort (No. [%]) (n = 592)Lumpectomy + radiation No. [%]) (n = 156)Mastectomy (No. [%]) (n = 341)Mastectomy + reconstruction (No. [%]) (n = 95)
Age (y)
 <51264 (45)75 (48)129 (38)60 (63)
 51-64328 (55)81 (52)212 (62)35 (37)
Race
 White491 (83)132 (85)275 (81)84 (88)
 Black101 (17)24 (15)

Discussion

Breast reconstruction has been used for many years to treat the cosmetic defect of a modified radical mastectomy. Prosthetic implantation and flap procedures provide good cosmetic results and patient satisfaction.13, 22 However, less is known about what factors determine which women will undergo reconstruction.

From 1989 to 1991 only 26% of women less than 64 years old had BCS. However, the rate of BCS in this age group was comparable to that of other urban areas in the United States with large

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    Reprint requests: Christopher E. Desch, MD, Massey Cancer Center, Box 980037, Richmond, VA 23298-0037.

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