Patient Out-of-Pocket Costs and Healthcare Utilization Related to Mastectomy vs Breast Conservation: A Claims-Based Study.

BackgroundUtilization of bilateral mastectomy for unilateral breast cancer is increasing despite cost and surgical risks with conflicting reports of survival benefit. Current studies evaluating death after bilateral mastectomy have included patients treated both with breast conservation therapy and unilateral mastectomy. In this study, we directly compared breast cancer–specific death of patients who underwent bilateral or unilateral mastectomy for unilateral breast cancer using a matched cohort analysis.MethodsThis was an observational study of women diagnosed with unilateral breast cancer from 1998 through 2002, using the Surveillance, Epidemiology, and End Results (SEER) database. A 4-to-1 matched cohort of patients was selected including 14,075 patients. Mortality of the groups was compared using Cox proportional hazards models for cause-specific death.ResultsA total of 41,510 patients diagnosed with unilateral breast cancer were included. Unilateral mastectomy was performed in 93% of patients, while bilateral mastectomy was performed in the remaining 7% of patients. When 4-to-1 matching was performed, 11,260 unilateral mastectomy and 2,815 bilateral mastectomy patients were included. Patients with bilateral mastectomy did not have a significantly lower hazard of breast cancer–specific death when compared with patients with unilateral mastectomy (hazard ratio: 0.92 vs 1.00, p=0.11).ConclusionBilateral mastectomy did not provide a clinically or statistically significant breast cancer–specific mortality benefit over unilateral mastectomy based on a matched cohort analysis of a nationwide population database. These findings should be interpreted in the context of patient preference and alternative benefits of bilateral mastectomy.

570 Background: Rates of bilateral mastectomy continue to rise in average-risk women with unilateral breast cancer. We aim to characterize psychosocial predictors of surgical procedure and how psychosocial outcomes change over time after surgery for breast cancer. Methods: A prospective cohort of women with unilateral, nonhereditary breast cancer were recruited at University Health Network in Toronto, Canada between 2014-2017. Women completed validated psychosocial questionnaires (BREAST-Q) pre-operatively, and 6 and 12 months after surgery. Outcomes were assessed between three surgical groups (unilateral lumpectomy, unilateral mastectomy, bilateral mastectomy). Predictors of surgical procedure were identified using a multinomial logistic regression model. Change in psychosocial scores over time according to procedure was assessed using linear mixed models. All models control for age, stage, reconstruction and treatment. P values < .05 were considered statistically significant. Results: 506 women underwent surgery as follows: 216 unilateral lumpectomy (43%), 181 unilateral mastectomy (36%) and 109 bilateral mastectomy (22%). In the multinomial regression model, younger age (p < .01), and lower chest physical (p = .03) and sexual well-being (p = .02) predicted having bilateral mastectomy over unilateral lumpectomy while younger age (p < .01) and lower disease stage (p = .02) predicted bilateral mastectomy over unilateral mastectomy. The mixed model demonstrates that breast satisfaction follows a non-linear pattern of change over time, with 6- but not 12-month scores being significantly different from baseline (p = .015). Procedure predicts baseline satisfaction (p = .016), with bilateral mastectomy having worse satisfaction than unilateral lumpectomy. Procedure also predicts change in satisfaction, with unilateral and bilateral mastectomy having lower scores across time than lumpectomy. While a significant improvement in psychological well-being is detected by 12 months (p = .02), those with unilateral and bilateral mastectomy have worse psychological well-being over time compared to lumpectomy. Women having mastectomy start with worse physical well-being than those in the lumpectomy group, but their physical well-being does not decline as much as the lumpectomy group over time (p < .01). Conclusions: Definitive surgical procedure affects the trajectory of psychosocial functioning over time. This emerging data may be used to further facilitate surgical decision-making in women considering contralateral prophylactic mastectomy.

OBJECTIVE To evaluate potential associations between surgical approach and complication rate, progression-free survival time, and disease-specific survival time in cats with mammary adenocarcinoma. DESIGN Retrospective case series. ANIMALS 107 client-owned cats. PROCEDURES Medical records of cats that underwent surgical excision of mammary adenocarcinoma by means of a unilateral or bilateral (staged or single-session) mastectomy at 9 hospitals between 1991 and 2014 were reviewed. Relevant clinicopathologic data and details of surgical and adjuvant treatments were recorded. Outcome data were obtained, including postoperative complications, progression-free survival time, and disease-specific survival time. RESULTS Complications occurred in 12 of 61 (19.7%) cats treated with unilateral mastectomy, 5 of 14 (35.7%) cats treated with staged bilateral mastectomy, and 13 of 32 (40.6%) cats treated with single-session bilateral mastectomy. Complications were significantly more likely to occur in cats undergoing bilateral versus unilateral mastectomy. Median progression-free survival time was longer for cats treated with bilateral mastectomy (542 days) than for cats treated with unilateral mastectomy (289 days). Significant risk factors for disease progression included unilateral mastectomy, tumor ulceration, lymph node metastasis, and tumors arising in the fourth mammary gland. Significant risk factors for disease-specific death included lymph node metastasis and development of regional or distant metastasis. Among cats that did not develop metastasis, unilateral mastectomy was a significant risk factor for disease-specific death. Treatment with chemotherapy was associated with a significantly decreased risk of disease-specific death. CONCLUSIONS AND CLINICAL RELEVANCE Results supported bilateral mastectomy for the treatment of mammary adenocarcinoma in cats to improve progression-free and disease-specific survival time. Performing bilateral mastectomy in a staged fashion may help to decrease the complication rate.

Background: Breast cancer surgery has experienced an evolutional change from radical mastectomy to conservative techniques due to the migration of stage of disease at diagnosis and adjuvant use of multimodality treatment. While breast conservation is preferred by most, the trend of bilateral mastectomy has been on the rise in the United States. The aim of this study is to determine factors that may affect patients’ choice of bilateral mastectomy. Methods: This is a retrospective study of 376 patients diagnosed with primary invasive breast cancer who were treated by bilateral or unilateral mastectomy (BM or UM) at the Revlon/UCLA Breast Center between Jan. 2002 and Dec. 2010. Patients in the bilateral mastectomy (BM) group were further divided into groups of bilateral mastectomy for bilateral breast cancer and for unilateral breast cancer and contralateral prophylactic mastectomy. Results: When compared with the UM group, the following factors were found to be associated with the BM: younger age (p<0.001), pre-menopause (p<0.001), having a family history of breast cancer (p<0.001) or ovarian cancer (p=0.017), BRCA 1 and 2 mutations (p<0.001, p=0.011, respectively), more breast biopsies (p=0.007), history of breast augmentation (p=0.014), more MRI study within 6 months before the surgery (p=0.029), more likely to have reconstruction surgery (p<0.001) and sentinel lymph node biopsy (SLNB) (p<0.001). Multivariate analysis indicated that patients with smaller tumor size (p<0.001, OR 0.087), negative nodes (p<0.001), sentinel lymph node biopsy as nodal surgery (p<0.001, OR 0.259), BRCA mutation (p=0.020, OR 6.537) and positive family history (p=0.001, OR 2.732) were more likely to choose bilateral mastectomy with reconstruction using tissue expanders or implants (p<0.001, OR 4.546). Conclusion: Bilateral mastectomy is associated with lower TN stage, requiring only SNLB, presence of BRCA mutation and/or high risk family history. Tissue expanders or implants based reconstructions were more frequently chosen by patients with bilateral mastectomy. Citation Format: Yun Fu, Zhigang Zhuang, Michelle Dewing, Apple Sophia, Chang R Helena. Predictors of bilateral mastectomy in breast cancer patients [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P2-13-13.

585 Background: Many women with unilateral breast cancer opt for bilateral mastectomy. While removing the unaffected contralateral breast lowers the risk of second primary cancers, there is no benefit on breast cancer mortality. Studies have not investigated whether this holds true for invasive lobular carcinoma (ILC). To estimate the 20-year risk of breast cancer mortality in women with stage I-III unilateral ILC and compare survival outcomes between unilateral lumpectomy, unilateral mastectomy and bilateral mastectomy. Methods: This retrospective cohort study used the Surveillance, Epidemiology, and End Results (SEER) database to identify women diagnosed with unilateral invasive lobular carcinoma (ILC) between 2000 and 2020. The cohort was followed for up to 20 years to assess contralateral breast cancer and breast cancer-specific survival. We estimated crude mortality rates, 20-year cumulative breast cancer mortality, and hazard ratios by surgical treatment group. Kaplan-Meier was used for cumulative risk, and Cox proportional hazards models for unadjusted and adjusted hazard ratios with 95% confidence intervals. P-values < 0.05 were considered significant. Results: We identified 58,861 women with unilateral ILC. Of which, 34,561 (59%) had lumpectomy, 18,894 (32%) had unilateral mastectomy, and 5406 (9.1%) had bilateral mastectomy. The mean age (in years) was 64 ±11 for unilateral lumpectomy, 62 ±13 for unilateral mastectomy, and 57±11 for bilateral mastectomy (p < 0.0001). The mean tumour size was smallest in the lumpectomy group (1.9±1.5 cm) compared with 3.6± 3 cm in both unilateral and bilateral mastectomy groups (p < 0.0001). The 20-year cumulative invasive contralateral breast cancer risk was 7.3% for lumpectomy, 7.5% for unilateral mastectomy, and 0.3% for bilateral mastectomy. The 20-year cumulative breast cancer mortality was 13.4% in the lumpectomy group, 30.2% in unilateral mastectomy group and 24.3% in bilateral mastectomy group. However, after adjusting for demographic, clinical, and treatment variables, we observed no difference in breast cancer mortality rates among unilateral mastectomy patients versus lumpectomy patients (adjusted hazard ratio [aHR], 1.01; 95% CI, 0.94–1.08), and a statistically significant reduction in breast cancer mortality rates among bilateral mastectomy patients compared to lumpectomy patients (aHR, 0.90; 95% CI, 0.82–1.00; p value 0.04). Conclusions: In this cohort of invasive lobular breast cancer, bilateral mastectomy patients had a significantly lower risk of contralateral breast cancer and, after adjusting for differences in the surgical treatment groups, had a 10% lower rate of breast cancer mortality as compared to lumpectomy patients.

Objective: Rates of bilateral mastectomy are increasing in women with ductal carcinoma in situ (DCIS). We aim to characterize the trajectory of psychosocial outcomes after surgery in women with DCIS. Methods: We have been prospectively collecting psychosocial data on women receiving surgery for stage 0-III breast cancer at University Health Network in Toronto, Ontario, Canada since 2009. We queried our prospective database to identify all women receiving surgery for DCIS between May 2009 and January 2020. Women completed validated psychosocial questionnaires (e.g. BREAST-Q, Impact of Event Scale, Hospital Anxiety & Depression Scale) pre-operatively, and at 6 and 12 months following surgery. We analyzed the change in psychosocial scores between three surgical procedures (breast-conserving therapy, unilateral mastectomy and bilateral mastectomy) using linear mixed models, controlling for age and sociodemographic factors (e.g. ethnicity, education level, income and marital status). P values < .05 were significant. Results: 89 women with DCIS were identified, with a mean age of 52.4 ± 10.3 years. By surgical procedure, 7 women underwent breast-conserving therapy (8%), 46 underwent unilateral mastectomy (52%) and 36 underwent bilateral mastectomy (40%). Breast satisfaction (-8, P = .03) and sexual well-being (-10, P = .02) scores decreased over time but was not influenced by surgical procedure. Younger women had worse psychosocial well-being scores (-0.5/year, P = .02), with no impact of surgical procedure. There was a significant interaction between surgical procedure and time for chest physical well-being scores (P = .04); women having breast-conserving therapy had better chest physical well-being scores compared with both unilateral and bilateral mastectomy (with no difference between mastectomy groups). Unemployed women had worse chest physical well-being scores (-9, P = .04). There was a significant interaction between procedure and time for distress scores (P = .02); women having unilateral or bilateral mastectomy had higher distress scores before surgery but at 12 months, there was no difference between surgical procedures. Women with a higher annual income (≥80,000$) had higher breast satisfaction (+10, P = .03), psychosocial well-being (+14, P = .004), and sexual well-being (+12, P = .02), and lower distress (-12, P = .004 ) scores than women earning less than 80,000$ per year. There was a significant interaction (P = .01) between procedure and time for anxiety scores; while all surgical groups had mild anxiety scores at baseline, the anxiety scores for both unilateral and bilateral mastectomy groups improved to normal range over time while scores for women having breast-conserving therapy remained mild. Conclusions: Surgical procedure influences chest physical well-being, distress and anxiety scores in women with DCIS. Our data may help inform surgical decision-making for women with DCIS, and highlight a need for identifying women with high distress at diagnosis who may benefit from targeted psychosocial support. Citation Format: David W. Lim, Helene Retrouvey, Isabel Kerrebijn, Benita Hosseini, Anne C. O'Neill, Tulin D. Cil, Toni Zhong, Stefan O.P. Hofer, David R. McCready, Kelly A. Metcalfe. Does surgical procedure influence psychosocial outcomes after treatment in women with ductal carcinoma in situ? [abstract]. In: Proceedings of the AACR Special Conference on Rethinking DCIS: An Opportunity for Prevention?; 2022 Sep 8-11; Philadelphia, PA. Philadelphia (PA): AACR; Can Prev Res 2022;15(12 Suppl_1): Abstract nr B020.

Our objective was to quantify the cumulative total and out-of-pocket (OOP) costs for 3 non-metastatic prostate cancer treatment modalities: radiation, surgery, and conservative management at intervals of 1-, 3-, and 5-years post-diagnosis. We predicted these cumulative costs for a typical patient to improve cost transparency, facilitate conversations about potential costs, and to help advance non-metastatic prostate cancer cost evaluation. We used Merative™ MarketScan® Commercial Database data from 2007-2020. The cumulative total costs evaluated from the healthcare sector perspective were patient, clinician, and system/facility costs. We used descriptive statistics to summarize the sociodemographic characteristics of the cohort and a multivariable regression model to estimate the association between each treatment option (radiation, surgery, conservative management) and costs with inverse probability of treatment weighting (IPTW) to account for potential selection bias. We then predicted total and OOP costs defined by sample mode characteristics. This cohort included 74,324 patients. Cumulative total and OOP costs were significantly higher for radiation (p < 0.0001) and for surgery (p < 0.0001) at Years 1, 3, and 5 compared to conservative management. For a typical patient, total cumulative cost estimates for conservative management at Years 1/3/5 were: $15,896/$33,436/$48,110 and the cumulative patient OOP costs were: $2,003/$4,540/$6,621. The cumulative total costs for surgery at Years 1/3/5 were: $38,348/$49,424/$60,885 and the cumulative OOP costs were: $2,980/$5,255/$7,221. The cumulative total costs for radiation at Years 1/3/5 were: $65,397/$77,859/$91,497 and the cumulative OOP costs were: $3,151/$5,481/$7,504. For all years, the cumulative costs of radiation were highest, followed by surgery and conservative management, respectively. Radiation as the first treatment modality had higher costs compared to surgery and conservative management at the 3 time points. These cost estimates support non-metastatic prostate cancer treatment related cost transparency. These estimates can help researchers evaluate costs and facilitate patient-clinician cost conversations.

More women with unilateral early stage breast cancer are electing bilateral mastectomy (BM). Many cite anxiety, fear of recurrence, and certain aesthetic desires in their decision-making. Yet conflicting data exist regarding how these factors both inform and are modulated by medical decision-making, especially among women eligible for breast conservation (BCT). This study sought to assess the trajectories of women undergoing various surgical procedures for breast cancer. We performed a prospective longitudinal study of women with unilateral, non-hereditary breast cancer who underwent BCT, unilateral mastectomy (UM), or BM. Women completed surveys before surgery and at 1, 9, and 15months postop. Surveys included questions about treatment preferences, decisional control, the HADS-A anxiety scale, the Fear of Relapse/Recurrence Scale (FRRS), and the BREAST-Q. The Kruskal-Wallis test was used to compare outcomes between BCT, UM, and BM groups at each time point. 203 women were recruited and 177 (87.2%) completed 15-month follow-up. Of these, 101 (57.0%) underwent BCT, 33 (18.6%) underwent UM, and 43 (24.2%) underwent BM. Generalized anxiety and FRRS scores were similar between BCT, UM, and BM groups and declined uniformly after surgery. Although baseline breast satisfaction was similar between groups, at 15months, it was significantly lower in BM patients than in BCT patients. Women who felt "very" confident and "very" informed before surgery had lower anxiety, lower fear of recurrence, better psychosocial well-being (PSWB), and greater breast satisfaction at 15months. While patients who undergo mastectomy have less long-term breast satisfaction, all patients can expect to experience similar improvements in anxiety and PSWB. Efforts should be made to ensure that patients are informed and confident regardless of which surgery is chosen, for this is the greatest predictor of better outcomes.

Rates of bilateral mastectomy are rising in women with unilateral, nonhereditary breast cancer. We aim to characterize how psychosocial outcomes evolve after breast cancer surgery. We performed a prospective cohort study of women with unilateral, sporadic stage 0-III breast cancer at University Health Network in Toronto, Canada between 2014 and 2017. Women completed validated psychosocial questionnaires (BREAST-Q, Impact of Event Scale, Hospital Anxiety & Depression Scale) preoperatively, and at 6 and 12 months following surgery. Change in psychosocial scores was assessed between surgical groups using linear mixed models, controlling for age, stage, and adjuvant treatments. P < .05 were significant. A total of 475 women underwent unilateral lumpectomy (42.5%), unilateral mastectomy (38.3%), and bilateral mastectomy (19.2%). There was a significant interaction (P < .0001) between procedure and time for breast satisfaction, psychosocial and physical well-being. Women having unilateral lumpectomy had higher breast satisfaction and psychosocial well-being scores at 6 and 12 months after surgery compared with either unilateral or bilateral mastectomy, with no difference between the latter two groups. Physical well-being declined in all groups over time; scores were not better in women having bilateral mastectomy. While sexual well-being scores remained stable in the unilateral lumpectomy group, scores declined similarly in both unilateral and bilateral mastectomy groups over time. Cancer-related distress, anxiety, and depression scores declined significantly after surgery, regardless of surgical procedure (P < .001). Psychosocial outcomes are not improved with contralateral prophylactic mastectomy in women with unilateral breast cancer. Our data may inform women considering contralateral prophylactic mastectomy.

Rates of bilateral mastectomy (BM) have increased, but the impact on length of stay (LOS), readmission rate, 30-day mortality, and time to adjuvant therapy is unknown. Using the National Cancer Data Base, we selected 390,712 non-neoadjuvant AJCC stage 0-III breast cancer patients who underwent either unilateral mastectomy (UM) or BM from 2003 to 2010 with and without reconstruction. We used chi-square and logistic regression models for the analysis. A total of 315,278 patients (81 %) had UM, and 75,437 (19 %) had BM; 97,031 (25 %) underwent reconstruction. The number of median days from diagnosis to UM increased from 19 days in 2003 to 28 days in 2010, and for BM, increased from 21 to 31 days (p < 0.001). BM was independently associated with a longer time to surgery when adjusting for patient, facility, and tumor factors and reconstruction (OR 1.11; 95 % CI 1.07-1.15; p < 0.001). Reconstructed patients were twice as likely to have a longer time to surgery (OR 2.07; 95 % CI 2.01-2.14; p < 0.001). The median LOS was 1 day (range 0-184 days) for UM versus 2 (range 0-182) for BM (p < 0.001); 30-day mortality and readmission rates were not different between BM and UM. The median number of days from diagnosis to definitive chemotherapy, hormonal therapy, and radiation therapy was significantly greater in the BM group. Delays to surgical and adjuvant treatment are significantly longer for BM irrespective of reconstruction, and these delays have increased over the study period. These findings can be used by clinicians to counsel patients on BM.

Abstract #1095 Background: The preferred local treatment for women with early stage breast cancer (BC) without a genetic predisposition is breast conservation (BCS). However, in BRCA1/2 mutation carriers, bilateral mastectomy (BLM) at time of diagnosis may be a reasonable alternative. We sought to evaluate the impact that “upfront” genetic counseling and testing (GCT) may have on surgical decision-making in at-risk newly diagnosed BC patients and determine factors that may predict for BLM.&amp;#x2028; Methods: 225 consecutive stage 0-3 primary unilateral BC patients underwent GCT for BRCA1/2 germline mutations through the Cancer Genetics service at Dana-Farber Cancer Institute prior to definitive surgical treatment (defined as unilateral mastectomy, BLM or BCS with radiation therapy) from 2004-07. Demographics, BC characteristics, genetic counselor-obtained family cancer history, referring MD, definitive surgery and GCT results were extracted from medical records. Use of contralateral breast MRI as part of diagnostic work-up was assessed; results recorded as normal or abnormal if further imaging or biopsy were recommended (no additional cancers found). Myriad model was used to estimate pre-test probability of BRCA1/2 mutation. Bivariate predictors of surgical treatment were assessed; logistic regression was used to identify independent predictors of BLM.&amp;#x2028; Results: Mean age at BC diagnosis was 43.5 years (range 26-68) with TNM stage: 0 in 11.1%, I in 35.1%, II in 38.7% and III in 15.1%. Mean pre-test probability of a deleterious BRCA1/2 mutation was 12.3% (range 2.9%-51.4%). Results revealed BRCA1/2 mutation in 34 (15.1%), variant of unknown significance (VUS) in 14 (6.2%) and no mutation in 177 (78.7%) patients. BRCA1/2 positives were more likely to undergo BLM than patients testing negative (82.4% vs 19.8%; p&amp;lt;0.0001) or VUS (21.4%; p&amp;lt;0.0001). Overall, the strongest independent predictor of BLM was a positive genetic test result (OR 24.4; 95%CI 8.3-71.2). In patients testing negative, BLM was more common in those diagnosed age &amp;lt;40 (30.3% vs 13.5%; p&amp;lt;0.01) and in those with high Myriad scores (36% vs 17.1%; p&amp;lt;0.05). Referral for GCT by surgeon vs non-surgeon was associated with BLM (27.9% vs 15.5%; p&amp;lt;0.05). While having a contralateral breast MRI did not alter rates of BLM (MRI 16.7% vs No MRI 16.7%), an abnormal MRI finding was associated with BLM (42.9%; p=0.001). In multivariate logistic regression, abnormal MRI result was the strongest predictor of BLM in test negative patients (OR 7.5; 95%CI 2.2-25.8).&amp;#x2028; Discussion: While a positive genetic test was the strongest predictor of BLM in patients referred for GCT, high rates of BLM were observed even in women with negative results. Since patients are undoubtedly selected for GCT referral, the impact of age at BC diagnosis and family cancer history (Myriad score) may reflect issues of risk perception or communication by patients and providers. The influence of breast MRI on contralateral prophylactic mastectomy decisions in BC patients at diagnosis warrants further investigation. Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1095.

Objective: Although neoadjuvant chemotherapy (NAC) has not been shown to improve survival compared with adjuvant therapy for patients with operable invasive breast cancer (IBC), it is often used to allow more limited surgery in the breast and axilla without compromising local control. We sought to evaluate national trends in mastectomy among patients with operable breast cancer treated with NAC and to characterize the contribution of demographic and tumor characteristics to changing trends. Methods: We queried the National Cancer Database (NCDB) 2014 Participant User File for adult women who underwent surgery and received chemotherapy for unilateral T1-3N0-3M0 IBC diagnosed between 2010 and 2014. Surgery was classified as lumpectomy (BCS), unilateral mastectomy (UM) or bilateral mastectomy (BM). Molecular subtype was categorized according to ER, PR, and HER2 status. We used logistic regression to model surgery use (BM or UM vs BCS), adjusting for the following clinical covariates that were selected a priori: age, race/ethnicity, year of diagnosis, comorbidity score, metropolitan vs urban/rural residence, patient distance from treating facility, % with less than high school education (zip code based), insurance type, clinical stage, histology, and molecular subtype. As those who achieved pathologic complete response (pCR) after NAC should be ideal candidates for BCS, we also looked at this group separately. We then performed sensitivity analyses further controlling for region of the country and facility type, and for facility. Results: We identified 235,339 patients who fulfilled our inclusion criteria. Of these patients, 25.3% were treated with NAC. Rates of pCR increased from 33.3% in 2010 to 46.3% in 2014 (p&amp;lt;0.001). Rates of BCS increased from 37.0% in 2010 to 40.8% in 2014 (p&amp;lt;0.001). While rates of UM decreased from 43.3% in 2010 to 34.7% in 2014 (p&amp;lt;0.001), rates of BM with or without reconstruction increased from 19.7% in 2010 to 24.6% in 2014 (p&amp;lt;0.001). Rates of BM without immediate reconstruction remained stable over time, from 11.8% in 2010 to 11.5% in 2014. Among patients who received NAC, factors that were independently associated with both UM and BM (versus BCS) for both the entire cohort and those who achieved pCR included younger age, greater patient distance from facility, and higher clinical stage. Factors that were inversely associated with both UM and BM included black race and ductal histology. More recent year of diagnosis was inversely associated with UM and directly associated with BM. Asian race was associated with UM while non-Hispanic white race was associated with BM. Private or managed care insurance and higher area education were also associated with BM. These results were materially unchanged in sensitivity analyses. Conclusion: Rates of pCR have increased over time among patients with operable IBC treated with NAC. While the rate of UM has declined over time, the rate of BM has increased. Significant sociodemographic differences exist between women who undergo BCS, and women who undergo UM and BM. Further study of factors that influence surgical decision-making in the NAC setting is warranted. Citation Format: Pollom E, Qian Y, Dirbas F, Horst K, Tsai CJ. National trends in mastectomy for operable breast cancers treated with neoadjuvant chemotherapy [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-08-04.

There has been an increasing use of bilateral mastectomy (BM) for breast cancer. We sought to examine our trends among breast conservation (BCT) candidates and women recommended for unilateral mastectomy (UM). Our prospective breast cancer database was queried for women with a first-time, unilateral breast cancer. Patient and histologic factors and surgical treatment, including reconstruction, were evaluated. A detailed chart review was performed among patients from two representative time periods as to the reasons the patient underwent mastectomy. We identified 3,892 women between 2000 and 2012 of whom 60% underwent BCT, 1092 (28%) had UM and 12% underwent BM. BM rose from 4% in 2000 to a high of 19% in 2011, increasing around 2002 for women <40. BCT was less likely with decreasing age (p < 0.0001), lobular histology (p < 0.0001), higher stage (p < 0.0001) and decreasing BMI (p < 0.0001). Among mastectomy patients, contralateral mastectomy was associated with decreasing age (p < 0.0001), Caucasian race (p < 0.0001), and lower stage (p = 0.005). Over time, indications for mastectomy decreased while patients deemed BCT-eligible opting for UM or BM increased dramatically. Increases in the use of BM are in large part among women who were otherwise BCT-eligible. Factors associated with BM use are different for BCT-eligible patients and those recommended for UM. A better understanding of the factors driving individual patient choices is needed.

Introduction: Due to the low incidence of male breast cancer, large scale prospective trials to guide therapy are lacking. Historically males with breast cancer present at more advanced stages than females and have been surgically treated with modified radical mastectomy. Recent studies suggest that breast-conserving therapy for early-stage male breast cancer yields similar outcomes as for female patients, and that sentinel lymph node biopsy (SLNB) can be used in place of axillary lymph node dissection (ALND) for appropriate clinically node-negative patients. Our study investigates trends in breast and axillary surgery for male breast cancer patients, focusing specifically on the treatment of early-stage disease. Methods: The National Cancer Database (NCDB) was utilized to identify male and female patients diagnosed with clinical T1-2 breast cancer from 2004-2016. Patient, tumor, facility, and surgical treatment factors were examined. Patients were stratified by surgery type: partial, unilateral, and bilateral mastectomy; simple versus modified radical mastectomy; SLNB (removal of ≤ 5 lymph nodes) and ALND (&amp;gt;5 lymph nodes). Trends in surgery type were compared between male and female patients and over the study period for each gender. Results: 9,782 males and 1,078,105 females with T1-2 breast cancer were identified. Men were significantly older at diagnosis than women (31.4% vs. 23.6% age &amp;gt;70, p&amp;lt;0.0001), were more often insured by Medicare (44.5% vs. 35.3%, p&amp;lt;0.0001), and had greater co-morbidity (21.9% vs. 15.6% Charlson Deyo Score &amp;gt;0). ER/PR+ disease (94.2% vs. 84.1%, p&amp;lt;.0001), moderate/high grade histology (85.4% vs. 77.8%, p&amp;lt;.0001) and lymphovascular invasion (24% vs. 15.3%, p&amp;lt;.0001) were also more common in males vs. females. The majority of all patients were clinically node negative (80.4% of males, 85% of females) and had AJCC clinical stage I or II disease (92.3% men, 95.2% women). Unilateral mastectomy was performed most commonly for men (67.1% men vs. 24.1% women, p&amp;lt;0.001), while women more frequently underwent partial mastectomy (64.7% women vs. 26.4% men, p&amp;lt;0.001). The rates of each surgery type remained disparate by gender and stable over the study period: male unilateral mastectomy rate 59.8% in 2004 and 66.1% in 2016; female partial mastectomy rate 65.9% in 2004, 68.4% in 2016. Modified radical mastectomy rates decreased in favor of simple mastectomy for both genders, 61.8% to 24.1% in males and 58.7% to 20.2% in females, 2004 to 2016. There was a similar overall increase in SLNB vs. ALND for all patients, though SLNB was not adopted as the more common procedure in male patients until 2009. In 2016, 78.2% of females and 65.3% of males underwent SLNB vs. 51.1% and 39.8% in 2004, respectively. Conclusions: Although breast-conserving therapy is the treatment of choice for female patients with early-stage breast cancer and could be similarly used to treat men with T1-T2 disease, the majority of male breast cancer patients continue to undergo unilateral mastectomy for early-stage disease. In more recent years, SLNB has surpassed ALND for men, mirroring the trend for women, though in a more delayed and gradual fashion. Partial mastectomy and SLNB warrant consideration for men with T1 and T2 breast cancer, in particular since male breast cancer patients present at older ages and with more co-morbidity than their female counterparts, and may benefit from de-escalation of surgical treatment. Citation Format: Rashi Singh, Lifen Cao, Anuja L Sarode, Michael Kharouta, Robert Shenk, Megan E Miller. Trends in breast and axillary surgery for T1-T2 male breast cancer: A study from the national cancer database [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS14-12.

Given increasing costs of neurologic medications, there is a need to explore alternative options to minimize medication spending. To compare 2024 neurologic medication costs from commercial insurance plans with those available in the Mark Cuban Cost Plus Drug Company, a direct-to-consumer pharmacy. This cross-sectional study compared medication costs through a direct-to-consumer pharmacy with model-estimated 2024 costs from commercial and Medicare supplemental databases. Commercial insurance plan costs from 2012 to 2021 were used. The direct-to-consumer pricing for each medication was obtained from the website on December 10, 2024. The difference between direct-to-consumer and overall commercial insurance plan annual out-of-pocket (OOP) costs and total costs were calculated. Total and OOP costs were separately compared between direct-to-consumer and generic-only commercial prices. Aggregate cost differences were presented for OOP and total costs. Among 79 neurologic medications considered, 33 medications (42%) available for purchase through the direct-to-consumer pharmacy were studied. The direct-to-consumer pharmacy OOP costs were 75% higher and total costs were 413% lower than commercial pharmacies. Among observed medications, teriflunomide (-40%) and droxidopa (-18%) had lower OOP and total costs in the direct-to-consumer pharmacy, with no other medications having lower OOP costs in the direct-to-consumer pharmacy. In generic-only costs, no direct-to-consumer pharmacy medications had lower OOP annual cost. In total costs, 55% of the direct-to-consumer pharmacy medications had lower total annual cost. Teriflunomide (-5600%), droxidopa (-4800%), and dimethyl fumarate (-1900%) had the largest percentage reduction in the direct-to-consumer pharmacy. In aggregate, if all commercial prescriptions were filled in a direct-to-consumer pharmacy, the aggregate OOP expenditures would increase by $82 million. Practitioners should be aware of options such as direct-to-consumer pharmacies because they can often deliver similar OOP costs for uninsured patients to conventional pharmacies in commercial insurance plans. If pharmacies with direct-to-consumer pharmacy cost structures were widely used, total prescriptions may be markedly reduced.