Surgical and Financial Implications of Genetic Counseling and Requests for Concurrent Prophylactic Mastectomy

Abstract

Risk assessment evaluation and breast cancer (BRCA) testing can occur in situations where a woman considers herself to be at increased risk for developing breast cancer or her physicians, either during routine evaluation or after diagnosis of unilateral breast cancer, consider her to be at risk for harboring a genetic predisposition to breast malignancy. This study examined the impact of risk assessment counseling on trends in breast surgery and cost of care. A retrospective chart review was performed from January 1, 1999 to December 31, 2008 for women older than 18 years who underwent breast surgery for malignancy or prophylaxis, had at least 1-year follow-up, and underwent genetic counseling. From the total number of women treated at our institution who underwent unilateral or bilateral mastectomy, we identified 102 women who underwent genetic counseling and selected 199 patients who did not undergo counseling to create a 4:1 retrospective case-control study. Patients who underwent BRCA gene testing and/or counseling were compared with patients who did not (controls). The study was powered at 70%, and alpha was set at 0.05. Counseled patients were >9 times more likely to undergo bilateral mastectomies (odds ratio = 9.18). They were younger (46.4 vs. 61.8) and incurred higher total costs ($10,810 vs. $7,266) (P < 0.002). The same trend was observed in each group. In counseled and control groups, younger women chose bilateral mastectomies (mean 44.4; 55.5), whereas older women chose unilateral procedures (mean 49.8; 63.02) (P < 0.014). Total cost for bilateral mastectomies was greater than unilateral mastectomies for both groups. Of 55 counseled patients undergoing mastectomies (85 breasts), 78 (92%) breasts were reconstructed, whereas 113 (49%) of 230 breasts were reconstructed in the control group. There was a statistically significant association between counseling with BRCA testing and decision to undergo bilateral as opposed to unilateral mastectomies. Younger women were also more likely to choose bilateral mastectomies whether or not they underwent counseling. Furthermore, a greater proportion of counseled women who underwent reconstruction opted to have bilateral implants. At our institution, younger women tend to choose costlier options.

Early Onset Breast Cancer in a Registry-based Sample of African-American Women:BRCAMutation Prevalence, and Other Personal and System-level Clinical Characteristics

“…The association between bilateral mastectomy with family history suggests that genetic information (in the form of a family history of breast and/or ovarian cancer) may be considered by both patients and providers when deciding on the type of surgery for breast cancer treatment, consistent with that seen in Caucasians . Interestingly, the higher income level associated with bilateral mastectomy may be due to the higher costs , and requires further evaluation through a larger study.…”

Trends in Breast Reconstruction by Ethnicity: An Institutional Review Centered on the Treatment of an Urban Population

“…[15][16][17][18] This procedure is performed for patient peace of mind, elevated risk of contralateral disease, desire to avoid radiation, and family predisposition, whereas bilateral prophylactic mastectomy is typically performed in the setting of BRCA1/2 mutation. [19][20][21][22] There was no statistical significance in BRCA positive mutation status between ethnicity (P 4 0.72) or staging at time of FIG. 5.…”

Cost effectiveness of bilateral risk-reducing mastectomy and salpingo-oophorectomy

“…There are further studies calculating these costs in US and UK hospitals. For example, the costs for unilateral mastectomy or BRRM, defined as sole institutional costs for operating room and facility costs (without physician fees), were calculated as high as $ 7, 718 (unilateral) and $ 11,992 (bilateral mastectomy) in an US breast center in 2008 [35]. Published cancer care costs in American hospitals were integrated in the publication of Grann et al describing total costs (direct and indirect) for prophylactic mastectomy $ 10,591 and prophylactic salpingo-oophorectomy $ 6373 [36, 37].…”