Contralateral Prophylactic Mastectomy in the Era of Financial Toxicity: An Additional Point for Concern?

Incorporating Value-Based Decisions in Breast Cancer Treatment Algorithms

Given the excellent prognosis and availability of evidence-based treatment, patients with early-stage breast cancer are at risk of overtreatment. In this review, we summarize key opportunities to incorporate value-based decisions to optimize the delivery of high-value treatment across the breast cancer care continuum.

The underused potential of breast conserving therapy after neoadjuvant system treatment - Causes and solutions

Breast conserving therapy (BCT), consisting of breast conserving surgery and subsequent radiotherapy, is an equivalent option to mastectomy for women with early breast cancer. Although BCT after neoadjuvant systemic treatment (NAST) has been routinely recommend by international guidelines since many years, the rate of BCT worldwide varies largely and its potential is still underused. While the rate of BCT in western countries has increased over the past decades to currently about 70%, the rate of BCT is as low as 10% in other countries. In this review, we will evaluate the underused potential of breast conservation after NAST, identify causes, and discuss possible solutions. We identified clinical and non-clinical causes for the underuse of BCT after NAST including uncertainties within the community regarding oncologic outcomes, the correct tumor localization after NAST, the management of multifocal and multicentric tumors, margin assessment, disparities of socio-economic aspects on a patient and national level, and psychological biases affecting the shared decision-making process between patients and clinicians. Possible solutions to mitigate the underuse of BCT after NAST include interdisciplinary teams that keep the whole patient pathway in mind, optimized treatment counseling and shared decision-making, and targeted financial support to alleviate disparities.

A Comparison of Complications in Therapeutic versus Contralateral Prophylactic Mastectomy Reconstruction: A Paired Analysis

BACKGROUND

Although breast reconstruction after bilateral mastectomies including a contralateral prophylactic mastectomy is known to have a higher overall complication profile, whether reconstructive complication rates differ between the therapeutic mastectomy and contralateral prophylactic mastectomy sides remains unclear.

METHODS

Women undergoing bilateral mastectomies with autologous or implant-based breast reconstruction for a unilateral breast cancer at a single institution were identified (2009 to 2019). Postoperative complications were stratified by laterality (therapeutic mastectomy versus contralateral prophylactic mastectomy). Paired data were analyzed to compare the risks of complications between prophylactic and therapeutic reconstruction sides in the same patient.

RESULTS

A total of 130 patients (260 reconstructions) underwent bilateral autologous or implant-based reconstruction. Although most women underwent a simple mastectomy, a higher proportion of therapeutic mastectomies were modified radical mastectomies including axillary lymph node dissections compared to contralateral prophylactic mastectomies (15.4 percent versus 0 percent). Forty-four percent of women completed postmastectomy radiation therapy of the therapeutic side before definitive reconstruction. Overall, both therapeutic and prophylactic reconstructions had a similar incidence of reconstructive failure (p = 0.57), return to the operating room (p = 0.44), mastectomy skin flap necrosis (p = 0.32), seroma (p = 0.82), fat necrosis (p = 0.16), wound infection (p = 0.56), and cellulitis (p = 0.56). Nearly one-fifth of patients experienced complications limited to the prophylactic side [contralateral prophylactic mastectomy reconstruction complications, n = 26 (20.0 percent); therapeutic mastectomy reconstruction complications, n = 15 (11.5 percent)].

CONCLUSION

Despite a history of local radiation therapy and more extensive oncologic surgery on the therapeutic side, there are no significant differences in the incidence of postsurgical complications on the therapeutic mastectomy and contralateral prophylactic mastectomy sides after bilateral reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Area Deprivation Index and Rurality in Relation to Financial Toxicity among Breast Cancer Surgical Patients: Retrospective Cross-Sectional Study of Geospatial Differences in Risk Profiles

BACKGROUND

Financial toxicity (FT) depicts the burden of cancer treatment costs and is associated with lower quality of life and survival in breast cancer patients. We examined the relationship between geospatial location, represented by rurality and Area Deprivation Index (ADI), and risk of FT.

STUDY DESIGN

A single-institution, cross-sectional study was performed on adult female surgical breast cancer patients using survey data retrospectively collected between January 2018 and June 2019. Chart reviews were used to obtain patient information, and FT was identified using the COmprehensive Score for Financial Toxicity questionnaire, which is a validated instrument. Patients' home addresses were used to determine rurality using the Rural Urban Continuum Codes and linked to national ADI score. ADI was analyzed in tertiles for univariate statistical analyses, and as a continuous variable to develop multivariable logistic regression models to evaluate the independent associations of geospatial location with FT.

RESULTS

A total of 568 surgical breast cancer patients were included. Univariate analyses found significant differences across ADI tertiles with respect to race/ethnicity, marital status, insurance type, education, and rurality. In multivariable analysis, advanced cancer stage (odds ratio [OR] 2.26, 95% CI 1.15 to 4.44) and higher ADI (OR 1.012, 95% CI 1.01 to 1.02) were associated with worsening odds of FT. Increasing age (continuous) (OR 0.976, 95% CI 0.96 to 0.99), married status (vs unmarried) (OR 0.46, 95% CI 0.30 to 0.70), and receipt of bilateral mastectomy (OR 0.56, 95% CI 0.32 to 0.96) were protective of FT.

CONCLUSIONS

FT was significantly associated with areas of greater socioeconomic deprivation as measured by the ADI. However, in adjusted analyses, rurality was not significantly associated with FT. ADI can be useful for preoperative screening of at-risk populations and the targeted deployment of community-based interventions to alleviate FT.

Perceived financial decline related to breast reconstruction following mastectomy in a diverse population-based cohort

BACKGROUND

Despite mandated insurance coverage for breast reconstruction following mastectomy, health care costs are increasingly passed on to women through cost-sharing arrangements and high-deductible health plans. In this population-based study, the authors assessed perceived financial and employment declines related to breast reconstruction following mastectomy.

METHODS

Women with early-stage breast cancer (stages 0-II) diagnosed between July 2013 and May 2015 who underwent mastectomy were identified through the Surveillance, Epidemiology, and End Results registries of Georgia and Los Angeles and were surveyed. Primary outcome measures included patients' appraisal of their financial and employment status after cancer treatment. Multivariable models evaluated the association between breast reconstruction and primary outcomes.

RESULTS

Among 883 patients with breast cancer who underwent mastectomy, 44.2% did not undergo breast reconstruction, and 55.8% underwent reconstruction. Overall, 21.9% of the cohort reported being worse off financially since their diagnosis (25.8% with reconstruction vs 16.6% without reconstruction; P = .002). Women who underwent reconstruction reported higher out-of-pocket medical expenses (32.1% vs 15.6% with expenses greater than $5000; P < .001). Reconstruction was independently associated with a perceived decline in financial status (odds ratio, 1.92; 95% confidence interval, 1.15-3.22; P = .013). Among women who were employed at the time of their diagnosis, there was no association between reconstruction and a perceived decline in employment status (P = .927).

CONCLUSIONS

In this diverse cohort of women who underwent mastectomy, those who elected to undergo reconstruction experienced higher out-of-pocket medical expenses and self-reported financial decline. Patients, providers, and policymakers should be aware of the potential financial implications related to reconstruction despite mandatory insurance coverage.

Navigating the high costs of cancer care: opportunities for patient engagement

Over the past decade, the financial burden of cancer care on patients and their families has garnered increased attention. Many of the potential solutions have focused on system-level interventions such as adopting value-based payment models and negotiating drug prices; less consideration has been given to actions at the patient level to address cancer care costs. We argue that it is imperative to develop and support patient-level strategies that engage patients and consider their preferences, values and individual circumstances. Opportunities to meet these aims and improve the economic experience of patients in oncology are discussed, including: shared decision-making and communication, financial navigation and treatment planning, digital technology and alternative care pathways, and value-based insurance design.

Relationship Between Financial Toxicity and Surgical Treatment for Early-Stage Breast Cancer: A Propensity Score-Matched Comparison of Breast-Conserving Therapy and Mastectomy

BACKGROUND

Financial toxicity (FT) can lead to decreased quality of life and poor treatment outcomes. However, there is limited published data on the extent to which the various surgical treatment approaches for early-stage breast cancer are determinants for FT.

STUDY DESIGN

We performed a single-institution cross-sectional survey of adult female patients with stage 0 to II breast cancer undergoing unilateral breast-conserving therapy or unilateral mastectomy. FT was measured using the Comprehensive Score for Financial Toxicity (COST) survey. Propensity matching was performed to optimize comparability of study groups. A multivariate regression model was used to identify factors associated with worsening FT as a robustness check. Our secondary end point was prevalence of coping strategies associated with cost of cancer care.

RESULTS

Among 294 patients who met inclusion criteria, 203 underwent breast-conserving therapy and 91 received mastectomy. We generated 72 total matched pairs and noted no differences in demographic and socioeconomic characteristics. Of these, 55 pairs had complete COST information, which was comparable on adjusted analysis (26.6 vs 24.7; p = 0.481). High annual income (β = 4.83; p < 0.001) and supplemental insurance (β = 5.37; p < 0.001) were significantly associated with higher COST scores, while change in employment status (β = -4.81; p < 0.001) correlated significantly with lower COST scores. No significant differences were observed in coping strategies.

CONCLUSIONS

Choice of BCT or mastectomy was not associated with a differential risk for FT in early-stage cancer. Decisions on ablative approach should be made based on patient preferences and disease-specific criteria. Transparent counseling on FT for high-risk populations promotes patient-centricity.

Development of Machine Learning Algorithms for the Prediction of Financial Toxicity in Localized Breast Cancer Following Surgical Treatment

PURPOSE

Financial burden caused by cancer treatment is associated with material loss, distress, and poorer outcomes. Financial resources exist to support patients but identification of need is difficult. We sought to develop and test a tool to accurately predict an individual's risk of financial toxicity based on clinical, demographic, and patient-reported data prior to initiation of breast cancer treatment.

PATIENTS AND METHODS

We surveyed 611 patients undergoing breast cancer therapy at MD Anderson Cancer Center. We collected data using the validated COmprehensive Score for financial Toxicity (COST) patient-reported outcome measure alongside other financial indicators (credit score, income, and insurance status). We also collected clinical and perioperative data. We trained and tested an ensemble of machine learning (ML) algorithms (neural network, regularized linear model, support vector machines, and a classification tree) to predict financial toxicity. Data were randomly partitioned into training and test samples (2:1 ratio). Predictive performance was assessed using area-under-the-receiver-operating-characteristics-curve (AUROC), accuracy, sensitivity, and specificity.

RESULTS

In our test sample (N = 203), 48 of 203 women (23.6%) reported significant financial burden. The algorithm ensemble performed well to predict financial burden with an AUROC of 0.85, accuracy of 0.82, sensitivity of 0.85, and specificity of 0.81. Key clinical predictors of financial burden from the linear model were neoadjuvant therapy (βregularized, .11) and autologous, rather than implant-based, reconstruction (βregularized, .06). Notably, radiation and clinical tumor stage had no effect on financial burden.

CONCLUSION

ML models accurately predicted financial toxicity related to breast cancer treatment. These predictions may inform decision making and care planning to avoid financial distress during cancer treatment or enable targeted financial support. Further research is warranted to validate this tool and assess applicability for other types of cancer.

Current Practice and Perceptions Regarding Cost Communication in Breast Cancer Reconstruction: Survey Results of the American Society of Plastic Surgeons

BACKGROUND

Rising out-of-pocket costs (OOCs) are a major concern for breast cancer survivors. However, information on how plastic surgeons performing breast reconstruction (BR) perceive and communicate cost information is limited.

METHODS

An electronic, anonymous survey eliciting plastic surgeons' attitudes and behaviors regarding BR cost communication was distributed to active American Society of Plastic Surgery members. Questions were derived from previously published studies and entailed a 5-point Likert scale. Cost communication was identified based on dichotomized responses to the prompt, "I discuss the costs of breast reconstruction with my patients," and analyzed for associated factors.

RESULTS

Of the 5112 surgeons surveyed, 396 plastic surgeons responded (7.21%). Most of the surgeons reported having a sense of a patient's financial well-being (65%) and an awareness of treatment costs (66.9%). Most felt a responsibility to consider the impact of BR costs (69%). Although most of the surgeons expressed that they were comfortable having OOC discussions (58.9%), only a minority reported doing so routinely (24.2%). The fewest respondents (8.6%) cited OOC as an important variable for BR decision-making. Lack of supportive tools was the most cited barrier to having cost communication with patients (64.8%). Cost communication was identified in a minority (20.2%) of surgeon-patient encounters and had no significant relationship to surgeon demographics or practice setting.

CONCLUSIONS

Plastic surgeons rarely discuss costs of BR with patients despite having a high awareness of the topic and feeling comfortable with it. Prevailing attitudes about the importance of OOC and the lack of administrative support or cost information are likely the drivers of this mismatch and warrant further study.