Cost and Outcome Analysis of Breast Reconstruction Paradigm Shift

Background: Increasing use of bilateral mastectomies for treatment and prevention of breast cancer has generated an increased demand for bilateral breast reconstruction.  We analyzed shifts in reconstructive methods aimed at meeting combined goals of increased bilateral reconstruction and decreased morbidity. Cost and outcome endpoints were examined.

Methods:  A single institution series of 3,171 consecutive mastectomy cases over 10 years was divided into two periods: 1999–2004 and 2005-2010.  Cases all met criteria of minimum of 12 month follow-up.  Only the primary type of breast reconstruction performed with initial mastectomy was considered. Endpoints between the two periods were compared using two-tailed t-tests for continuous variables.

Results:  The incidence of bilateral mastectomy increased 2.6 fold from 1999-2004 (n=237) to 2005-2010 (n=634).  Unilateral mastectomy volume remained fairly constant from 1999-2004 (n=1104) to 2005-2010 (n=1196).  Mean patient age at diagnosis decreased by 7 years (p <0.001).  In 2005-2010, the autologous reconstruction rate decreased from 60% to 26%, while implant-based reconstruction increased from 40% to 74%.  Notable reconstructive paradigm shifts included increased single-stage implant reconstruction and selective application of perforator flaps for bilateral autologous reconstruction (p <0.001).  Two-staged tissue expander reconstruction accounted for the greatest share of total cost (45%).  Despite significant shifts in reconstruction methods, the overall complication and revision rates remained low.

Conclusions:  Changes in reconstructive methods toward decreasing morbidity was correlated with increased incidence of prophylactic mastectomy in younger patient demographic, with shift toward implant reconstruction. Single stage implant reconstruction in bilateral cases saw rapid adoption, while staged reconstruction with tissue expander accounted for the significant cost due to high volume.  Muscle sparing autologous reconstruction (DIEP) was applied selectively in bilateral cases.  This project provides the foundation for the detailed cost analysis necessary to evaluate changing oncologic and reconstructive trends and their costs on the health care system.