Contralateral Prophylactic Mastectomy in the Era of Financial Toxicity: An Additional Point for Concern?

Abstract

Over the past 2 decades, widespread screening and treatment innovations have resulted in improved overall survival and clinical outcomes across many cancer types. Unfortunately, this evolution has also come at substantial societal cost, as cancer is now the second most costly chronic condition in the United States with projected annual outlay of $157 billion in 2020.1 “Financial toxicity” describes the financial distress experienced by patients receiving treatment, resulting from rising oncology treatment costs increasingly being shouldered by patients themselves.2 Even among insured patients, cost-sharing has resulted in rising deductibles (ie, “high deductible health plans”), co-insurance levels, and premiums that are unaffordable for individuals receiving care. Lost productivity and work absenteeism further exacerbate treatment-related financial distress, which disproportionately impacts underinsured and minority patients.3 Among its many manifestations are poor physical and mental health, an increased risk of bankruptcy, treatment nonadherence, and early mortality.4 Cancer-related financial hardship is gaining well-deserved recognition as an impediment to the delivery of high-quality and value-based cancer care. In breast cancer care, evidence-based reductions in unnecessary chemotherapy and radiation have resulted in an appropriate and celebrated de-escalation of cancer therapies. Yet, paradoxically, rates of contralateral prophylactic mastectomy (CPM) have tripled in the past few decades, despite an absence of corroborating data showing additional medical benefit.5 Because of the National Surgical Adjuvant Breast and Bowel Project B-06 trial, longstanding randomized trial data and modern observational series have consistently demonstrated comparable local recurrence rates, disease-specific, and overall survival among women treated with breast conservation versus mastectomy. Among eligible women with early-stage breast cancer, shared decisions for surgery, including the extent of ablative surgery and post-mastectomy reconstruction, are, therefore, highly preference-sensitive. The best choice should be concordant with a woman's stated goals or values, and align with recommendations from the oncology team. Yet overwhelmingly, contemporary decisions for breast cancer surgery are cost blind, in that the financial implications related to treatment choice are not routinely addressed.6 As women face equally effective surgical options, cost transparency is especially salient. Overall, 30%–70% of cancer patients experience some form of treatment-related financial hardship, exceeding the risks of most surgical procedures7,8; not surprisingly, this is higher among patients seeking financial assistance. Recent guidelines from the American Society of Breast Surgeons and Choosing Wisely Campaign recommend that the routine use of CPM be discouraged in average-risk women.9 Although these guidelines endorse maintaining patient autonomy, they acknowledge the greater risk of perioperative complications and delays in adjuvant treatment associated with CPM, which are further exacerbated when combined with immediate breast reconstruction.10 Treatment-related complications have been associated with markedly increased financial hardship; in a 2014 study of colorectal cancer patients, complications were related to an increased need for loans, depleted savings, inability to repay debt, and altered spending on other activities.11 More recent data has suggested that more invasive cancer treatment, including bilateral mastectomy, is associated with a greater risk of patient-reported financial hardship.12 Lastly, it merits comment that women undergoing CPM are the same population at an elevated risk of financial hardship on account of their female sex, younger age (<50 years) at diagnosis, and private insurance status requiring higher out-of-pocket payments.13 Collectively, these findings raise questions about the quality of contemporary decision-making with respect to CPM if they are devoid of financial information and given the plausible increased risk of financial toxicity. Excluding cost implications from shared surgical decisions may inaccurately reflect the trade-offs between perceived advantages of CPM (ie, peace of mind, cosmetic symmetry post-reconstruction) and a differential risk of financial harm. Several studies have highlighted deficits in shared decision-making for CPM, including misperceptions of benefit among breast cancer patients, and poor patient-provider communication about the reality of potential harms. The American Society of Clinical Oncology has already endorsed the use of provider-patient cost discussions as a mechanism to reduce treatment-related financial hardship, and more recently, personal spending burden has been advocated as a core component of high-quality health care.14 However, this is necessary but not sufficient. As the oncology community aims to reduce overtreatment, and optimize the delivery of value-based breast cancer care, strong consideration should be given to greater integration of cost-conversations into decisions for CPM, where added surgery does not further improve excellent cancer outcomes. Ultimately, choice for CPM should be based on complete and authentic information, and align with women's values and priorities. For both patients and surgeons alike, this will require providing clear, easy-to-understand price information related to CPM at the initial point of care. Across the United States, individual surgical practices and widely varied healthcare settings will have different resource needs to address cancer-related financial hardship. Despite this, future research should focus on the common goal of better understanding how financial preparedness, access to cost information, and the impact of patient-provider cost communication may improve decisions for CPM as they relate to financial toxicity. Tacit to this cultural shift is the need to synchronously improve cost and health literacy among breast cancer patients. Providers should be emboldened to communicate the importance of value, not only to the healthcare system but to individuals receiving care. This is especially important to populations that are vulnerable to financial distress, including at-risk racial minorities, young patients, high-deductible enrollees, and those with unsubstantial social support. As women face decisions for CPM, surgeons invest in ensuring that women understand the benefits and potential harms of their personal choice- the risk of financial hardship should be no exception.