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Prophylactic Mastectomies: Implications Of Occult Histology And Lifetime Cost Of Surveillance Versus Surgery
David Mattos, MD, MBA, Lisa Gfrerer, MD, Richard G. Reish, MD, Kevin S. Hughes, MD, Elkan F. Halpern, PhD, Curtis Cetrulo, MD, Amy S. Colwell, MD, Jonathan M. Winograd, MD, Michael J. Yaremchuk, MD, William G. Austen, Jr., MD, Eric C. Liao, MD, PhD.
Massachusetts General Hospital, Boston, MA, USA.

PURPOSE: Despite the increasing incidence of prophylactic mastectomies (PM) in the last decade, data is limited on their detection of histological abnormalities or the fiscal impacts of this trend. We aimed to measure the occult pathologic finding rate, clinical predictors, and lifetime cost of surveillance versus prophylactic mastectomy with reconstruction.
METHODS: PM cases from over 1,100 records spanning 2004-2011 were reviewed. Predictive patient factors were identified with multivariate analysis. Costs were estimated with Medicare reimbursement rates. Contralateral (CPM) or bilateral prophylactic mastectomies (BPM) were compared to surveillance in a 30-year model. Published cancer incidence rates predicted the percentage of surveillance patients that would require mastectomies.
RESULTS: 454 patients with 524 specimens were identified. 7.3% of the CPM patients and 11.4% of the BPM patients had malignancies. Ipsilateral lobular carcinoma in situ (LCIS) was predictive of malignancy in CPM patients (OR = 3.7, P-value = 0.002). There were no predictors of malignancy in BPM. BRCA status was not predictive. In cost estimates, BPMs were $2,835 to $5,762 less than surveillance, depending on reconstruction method. Average CPMs were cost saving if the incidence of contralateral breast cancer in surveillance reached 0.6% per year.
CONCLUSION: Cancer patients with LCIS in the index breast benefit most from CPM. Lifetime cost estimates for PM vs. surveillance suggest that BPM is cost-saving and CPM comparable to surveillance. Decisions regarding PM should be made without interference of cost concerns.


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