Cost and complications of local therapies for early-stage breast cancer

Background: Guideline-concordant local therapy options for early breast cancer include lumpectomy plus whole breast irradiation (LumppWBI), lumpectomy plus brachytherapy, mastectomy alone, mastectomy plus reconstruction, and, in older women, lumpectomy alone. We performed a comparative examination of each treatment's complications and cost to assess their relative values. Methods: Using the MarketScan database of younger women with private insurance and the SEER-Medicare database of older women with public insurance, we identified 105 211 women with early breast cancer diagnosed between 2000 and 2011. We used diagnosis and procedural codes to identify treatment complications within 24 months of diagnosis and compared complications by treatment using two-sided logistic regression. Mean total and complication-related cost, relative to LumppWBI, were calculated from a payer's perspective and adjusted for differences in covariables using linear regression. All statistical tests were two-sided. Results: LumppWBI was the most commonly used treatment. Mastectomy plus reconstruction was associated with nearly twice the complication risk of LumppWBI (Marketscan: 54.3% vs 29.6%, relative risk [RR] = 1.87, 95% confidence interval [CI] = 1.82 to 1.91, P < .001; SEER-Medicare: 66.1% vs 37.6%, RR=1.75, 95% CI=1.69 to 1.82, P < .001) and was also associated with higher adjusted total cost (Marketscan: $22 481 greater than Lump-WBI; SEER-Medicare: $1748 greater) and complicationrelated cost (Marketscan: $9017 greater; SEER-Medicare: $2092 greater). Brachytherapy had modestly higher total cost and complications than WBI. Lumpectomy alone entailed lower cost and complications in the SEER-Medicare cohort only. Conclusions: Mastectomy plus reconstruction results in substantially higher complications and cost than other guidelineconcordant treatment options for early breast cancer. These findings are relevant to patients evaluating their local therapy options and to value-based population health management.