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A Cost-utility Analysis Comparing Large Volume Displacement Oncoplastic Surgery to Mastectomy with Free Flap Reconstruction in the Treatment of Breast Cancer
Abhishek Chatterjee, MD, MBA1, Ammar Asban, MD2, Lilian Chen, MD1, Carla Fisher, MD3.
1Tufts Medical Center, Boston, MA, USA, 2University of Alabama, Birmingham, AL, USA, 3University of Pennsylvania, Philadelphia, PA, USA.

PURPOSE: Breast cancer surgical treatment may include large volume displacement oncoplastic surgery (LVOS) or mastectomy with free flap reconstruction (MFFR). Reduction mammaplasty designs are used in the oncoplastic reconstructions. The goal of this study was to investigate the cost-utility between LVOS versus MFFR to determine which approach was cost-effective in the treatment of breast cancer.
METHODS: A review of the literature helped calculate probabilities for clinical outcomes for each surgical option (LVOS versus MFFR), and helped obtain utility scores that were converted into quality adjusted life years (QALYs) as measures for clinical effectiveness. Average Medicare payments were surrogates for cost. Whole breast radiation was assumed for LVOS. A decision tree was constructed and an incremental cost-utility ratio (ICUR) was used to calculate cost-effectiveness. RESULTS: The decision tree (Figure 1) shows the associated QALYs, costs and probabilities used to calculate the ICUR of $3,699/QALY with gain of 2.7 QALYs at an additional cost of $9,987 proving that LVOS is cost-effective. One-way sensitivity analysis showed that LVOS became cost-ineffective when its clinical effectiveness had a QALY of less than 30.187. Probabilistic sensitivity analysis using Monte-Carlo simulation showed that even with varying multiple variables at once, results tended to favor our conclusion.
CONCLUSION: Large volume oncoplastic surgery is cost-effective in breast cancer treatment compared to mastectomy with free flap reconstruction providing another surgical option for the breast cancer patient.


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