A Cost–Utility Analysis Comparing Immediate Oncoplastic Surgery to Delayed Oncoplastic Surgery in Smoking Breast Cancer Patients

Abstract

PURPOSE: Oncoplastic surgery allows for lower positive margin rates and improved aesthetic outcomes compared with traditional breast conservation surgery.1 A Level 2 volume displacement oncoplastic surgery (LVOS) (also known as an oncoplastic reduction) allows for a large partial mastectomy through a reduction mammoplasty incision and is ideal for breast cancer patients with macromastia. Typically, a concurrent ipsilateral reduction mammoplasty is also performed.2,3 However, if the patient is a smoker, the decision to perform a concurrent reconstruction is challenging. It can be argued that in order to allow sufficient time for the patient to stop smoking, reconstruction should be delayed until after adjuvant radiation. However, radiation can also cause poor wound healing and can increase the risk of a wound-related complication. LVOS with immediate and delayed reconstruction are associated with different clinical outcomes and costs. Our aim was to examine the cost–utility of immediate versus delayed reconstruction in LVOS when operating on a smoking patient with macromastia and a long-term commitment to smoking cessation. METHODS: A literature review was performed to determine the probabilities and outcomes related to the treatment of unilateral breast cancer with immediate or delayed reconstruction with LVOS.1–3 Reported utility scores were used to estimate the quality adjusted life years associated with a successful procedure as well as postoperative complications. A decision analysis tree was constructed with rollback analysis to highlight the more cost-effective strategy. An incremental cost–utility ratio was calculated. Single variable and probabilistic sensitivity analyses were performed to validate the robustness of the results. RESULTS: Immediate LVOS is associated with a higher clinical effectiveness (quality adjusted life years) of 33.3 compared with delayed (33.26), with a higher increment of clinical effectiveness of 0.07 and relative cost reduction of $3458.11. This resulted in a negative incremental cost–utility ratio of −50,194, which was in favor of immediate reconstruction, indicating a dominant strategy. In 1-way sensitivity analyses, delayed reconstruction was the more cost-effective strategy if the probability of successful immediate reconstruction falls below 29% or its cost exceeds $29,611. Monte Carlo analysis showed a confidence of 99% that immediate oncoplastic surgery costs less and is the more effective strategy. CONCLUSIONS: Despite the known risk of postoperative complications associated with smoking, immediate LVOS is more cost-effective compared with delayed LVOS. The risks of postoperative complications are higher when operating on a radiated breast in the delayed setting, thus favoring immediate LVOS. REFERENCES: 1. Munhoz AM, Aldrighi CM, Montag E, et al. Outcome analysis of immediate and delayed conservative breast surgery reconstruction with mastopexy and reduction mammaplasty techniques. Ann Plast Surg. 2011;67:220–225. 2. Asban A, Homsy C, Chen C, et al. A cost-utility analysis comparing large volume displacement oncoplastic surgery to mastectomy with single stage implant reconstruction in the treatment of breast cancer. Breast. 2018;41:159–164. 3. Chatterjee A, Offodile II AC, Asban A, et al. A cost-utility analysis comparing oncoplastic breast surgery to standard lumpectomy in large breasted women. Adv Breast Cancer Res. 2018;7:187–200.