Post Mastectomy Tissue Expander Placement followed by Radiation Therapy: A Cost-effectiveness Analysis of Staged Autologous vs. Implant-based Reconstruction

Abstract

PURPOSE: There is no clearly preferred approach to breast reconstruction in patients with locally advanced breast cancer who require post-mastectomy radiation therapy (PMRT). Staged implant and deep inferior epigastric perforator (DIEP) flap reconstruction each have unique risks and benefits. No previous study compares the cost-effectiveness of these approaches with validated utility scores. METHOD: A literature review looking at prospective trials determined the probabilities and outcomes for mastectomy and staged implant reconstruction or staged DIEP flap reconstruction. Utility scores were used to calculate the quality adjusted life years (QALYs) associated with a successful procedure and post-operative complications. Medicare current procedure terminology and diagnosis-related group codes were used to assess the costs for a successful surgery and associated complications. A decision analysis tree was constructed with rollback analysis to highlight the more cost-effective strategy. An incremental cost-effectiveness ratio (ICER) analysis was performed with a willingness to pay at $50,000. Deterministic and probabilistic sensitivity analyses were performed to validate the robustness of the results, and to account for uncertainty in the data. RESULTS: Mastectomy with staged DIEP flap reconstruction is costlier ($14,104.80 versus $3,216.93), but more effective (29.96 versus 24.87) compared to staged implant reconstruction. This resulted in an ICER of 2141.00, which favored DIEP flap reconstruction, indicating a dominant strategy. In one-way sensitivity analysis, DIEP flap reconstruction was the more cost-effective strategy if the cost was less than $257,444.13. Monte Carlo analysis showed a confidence of 99.99% that DIEP flap reconstruction is more cost-effective. CONCLUSION: For patients with locally advanced breast cancer who require PMRT, mastectomy followed by staged DIEP flap reconstruction is significantly more cost-effective when compared with staged implant reconstruction. Despite the decreased morbidity, staged implant reconstruction has much greater rates of complication in irradiated fields including capsular contracture and infection.