You’ve been looking at complications and the economic burden of whatever decision the patients and their doctors take about local therapy. Now that’s very interesting because there are quite a wide number of options, can you tell me why, though, you particularly thought this was important to study?
Sure. Probably once or twice a month I may see a patient who comes to MD Anderson and she’s just been diagnosed with breast cancer and if you look up on the NCCN guidelines there are patients who could appropriately be treated with lumpectomy and nothing else, lumpectomy and brachytherapy, lumpectomy and whole breast radiation, mastectomy or even mastectomy and reconstruction. So one patient could be choosing and we may be counselling her about all five of those different treatment options.
It’s important that women actually understand all of the different consequences of the various choices. It’s not just a medical or scientific decision, is it?
Exactly and so far there haven’t been any good studies that specifically look at all those treatments and align the different complications and compare them from treatment to treatment.
So what did you do in the study that you’ve now reported here at the San Antonio Breast Cancer meeting?
We put together two very large cohorts of patients, one cohort of older patients with Medicare insurance and one cohort of younger patients with private insurance. We looked at the complication burden of the different treatments and then we also looked at the cost.
Why did you go for the state financed treatment as compared with the private treatment?
Well the state financed treatment is a little cleaner cohort because you have patient information linked to their tumour data so that makes it a little easier to study. But we were also particularly interested in mastectomy and reconstruction and that’s fairly infrequently used in older patients but much more commonly used in younger patients.
So what did you do?
We looked at these two cohorts and we looked at complications as determined by medical claims, by the insurance claims, and then we did statistical models to see how the treatment was associated with the complication.
So there are complications, also cost is too.
Yes, we also looked at cost. We looked at total cost, complication related cost and then the difference between the two.
And your findings?
We found that in both cohorts there was almost a doubling in the risk of complication with mastectomy and reconstruction compared to lumpectomy and whole breast irradiation. We also found that there was a fairly high burden of cost imposed by complications of mastectomy and reconstruction reaching about $10,000 per patient for younger women with private insurance.
And mastectomy without reconstruction, then, did better, did it?
Very low complication rates and much lower cost.
What are your understandings coming out of these facts, then?
I think our understanding is that there are some treatments that appear to have higher value than others when viewed through the lens of the complication and the cost. That’s really helpful for patients, it’s also helpful for society to think about how we want to invest our resources to give patients the highest value and the highest quality care.
Of course, you may have higher complication risk and higher costs but it may still be highly desirable for a woman to have the reconstruction with the mastectomy.
Yes, so if you have to have a mastectomy it still may be totally worth it to do the reconstruction. But if you’re sitting here and you don’t have to have the mastectomy and you can get away with something a lot simpler, well maybe that’s the way to go.
There has also been a comment here, I believe, about the difference between autologous tissue reconstruction or having an implant.
Right, so we looked at that a little bit, and we didn’t have time to present all that data, but we found that implant was a little less expensive than autologous and seemed to have a slightly better complication profile within the first two years.
Where does this leave the discussion between whether to have lumpectomy or mastectomy in women who could well choose either?
If retaining a breast mound is important to you as a patient, a lumpectomy based strategy is an easier way to achieve that outcome. If, as a patient, you don’t really care and you’d be happy to just have a mastectomy and leave it at that, our data indicate that that’s also a low complication, high value treatment.
We’ve also been hearing here in San Antonio that lumpectomy has quite a good health record too, doesn’t it?
Yes, so the randomised trial data indicate that survival is essentially equivalent between lumpectomy and radiation and mastectomy. So that’s reassuring, so that’s one of the reasons I have a job as a radiation oncologist.
Could you pull this together for me in terms of your summary of what doctors need to understand coming out of the facts that you’ve assembled on complications and costs in the different options for local therapy in breast cancer?
What we’ve found is that for women who wish to retain a breast mound, either their native one or a reconstructed one, we found that for young women lumpectomy and whole breast radiation appears to be the highest value treatment. For older women either lumpectomy alone or lumpectomy plus whole breast irradiation appear to be the highest value treatments.
And if you go for reconstruction then what then? What is your advice then?
So if you have to have a mastectomy then it’s fine to go for reconstruction as well but there is an increased burden of complications so you’ll just want to make sure you pick a good plastic surgeon who is going to work with you to give you the very best outcomes possible.
The overall take home message for doctors, then, is what?
For doctors, you could say that our findings would suggest that less is a little bit more with regard to minimising complication and optimising value.