Cost Analysis of a Surgical Consensus Guideline in Breast-Conserving Surgery

Abstract

Background The SSO/ASTRO consensus statement was the first professional guideline in breast oncology to declare “no ink on tumor” as a negative margin in patients with stages I/II breast cancer undergoing breast conservation therapy (BCT). We sought to analyze the financial impact of this guideline at our institution using a historic cohort. Study Design We identified women undergoing re-excision following breast-conserving surgery for invasive breast cancer from 2010–2013 using a prospectively-maintained institutional database. Clinical and billing data were extracted from the medical record and from administrative resources using CPT codes. Descriptive statistics were used in data analysis. Results Of 254 women in the study population, 238 (93.7%) had stage I/II disease and 182 (71.7%) had invasive disease with DCIS. A subcohort of 83 patients (32.7%) who underwent BCT for Stage I/II disease without neoadjuvant chemotherapy had negative margins after the index procedure per the SSO/ASTRO guideline. The majority had invasive ductal carcinoma (70, 84.3%) and had invasive disease (45, 54.2%) and/or DCIS (49, 59.0%) within 1 mm of the specimen margin. Seventy-nine patients underwent one re-excision, and 4 patients underwent two re-excisions, accounting for 81 hours of operative time. Considering facility fees and primary surgeon billing alone, the overall estimated cost reduction would have been $195,919, or $2,360 per affected patient, under the guideline recommendations. Conclusions Implementation of the SSO/ASTRO consensus guideline holds great potential to optimize resource utilization. Application of the guideline to a retrospective cohort at our institution would have decreased the overall re-excision rate by 5.6% and reduced costs by nearly $200,000. Further analysis of patient outcomes and margin assessment methods is needed to define the long-term impact on surgical practice.

<p>Positive margins (R1) risk factors in breast cancer conservative surgery</p>

“…In this era of multidisciplinary therapy, “no ink on tumor” is now becoming a standard policy to grasp the appropriateness of the margins in surgery operations. In fact, it is associated with low rates of ipsilateral true breast tumor recurrence and has the potential to decrease re-excision rates, improve cosmetic outcomes and decrease health care cost 13,14…”

Patient-level costs in margin re-excision for breast-conserving surgery

“…Only direct medical costs were reported; indirect costs (not directly accountable to the operation) and intangible costs (unquantifiable cost relating to an identifiable source) were not estimated in any of the reviewed literature. The source of cost estimates was hospital records in four studies and Centers for Medicare and Medicaid Services reimbursement data in three. Initial BCS and reoperation costs were in the range US $1234–11786 and $655–9136 respectively ( Table S2, supporting information).…”

“…The present health economic review highlights the heterogeneity and paucity of high‐quality studies reporting cost estimates of reoperations in breast surgery. Only nine studies have commented on reported costs of re‐excision in BCS, with two employing a predictive model to hypothesize the cost impact of re‐excision following BCS in the USA and Canada. Several studies contained minimal cost information, whereas others reported a range of costs for numerous variables that could not be collated accurately.…”

“…Although there have been a number of reports describing the cost burden associated with reoperations after breast surgery, there has been no attempt to review or synthesize this literature. Moreover, investigators have attempted to define the costs of reoperations after BCS using best estimates of patient charges or decision models that use hypothetical cohorts. Although there is an obvious cost burden to health systems, the idiosyncratic nature of costing methodologies used creates uncertainty around the magnitude and location of cost drivers across the BCS care pathway.…”

The Influence of Breast Density on the Utility of MarginProbe in Partial Mastectomy

“…1 Numerous studies have also suggested a negative financial and social impact associated with the need for re-excision. 2 Most surgeons agree that achieving negative margins at the initial surgery can significantly improve cosmetic outcome as well. As frozen sections are impractical because of both the need for additional operating room times (up to 30 minutes) and variable accuracy and physical availability of staff and/or equipment for routine partial mastectomy, various modalities have been developed to reduce the risk of a positive margin.…”