Systematic review of cost-effectiveness in breast reconstruction: deep inferior epigastric perforator flap vs. implant-based breast reconstruction

Abstract

Background: There are several techniques for reconstructing breasts after mastectomy, but little scientific evidence for which technique is superior. The aim of this systematic review was to compare the cost-effectiveness of implant-based and autologous reconstruction and to evaluate the overall certainty of evidence, as well as the quality of reporting of the included studies. Methods: Studies investigating the cost-effectiveness of breast reconstruction with a deep inferior epigastric perforator (DIEP) flap compared to implant-based reconstruction, meeting criteria defined in a PICO (population, intervention, comparison, and outcome), were included. Medline, PubMed, Embase, Cochrane library, CinahL, EconLit, and NHS EED databases were searched. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess the certainty of evidence, and the Consolidated Health Economic Evaluation Reporting Standard (CHEERS) 2022 was used to evaluate the quality of reporting. Results and conclusions: A total of 256 abstracts were retrieved from the search, and after scrutiny, seven studies were included. The findings of this present systematic review should be interpreted with caution as the overall certainty of evidence is low (GRADE ƟƟОО). The included studies suggest that DIEP-flaps are cost-effective compared with implant-based breast reconstruction when the applied cost-effectiveness thresholds of $50,000 to $100,000 per quality-adjusted life years are used. It is noteworthy that no high level evidence exists regarding cost-effeciency, to support recommendations and decision in breast reconstruction. Methodological issues that can be improved in future studies are presented.

Gothenburg Breast reconstruction (GoBreast) II protocol: a Swedish partially randomised patient preference, superiority trial comparing autologous and implant-based breast reconstruction

“…A systematic review on health economics in breast reconstruction has demonstrated that there is no high-level evidence, regarding cost-effectiveness, to support recommendations and decisions in breast reconstruction. 8 The review 8 identified several methodological issues, such as a lack of a societal perspective, usage of standardised and validated methods to evaluate benefits, and modelling approaches not compatible with the reconstructive reality. The identified methodological weaknesses have formed the basis of the design of the present study.…”

“…However, most of the included studies were retrospective, non-randomised, did not correct for other factors that might affect satisfaction, and had a short follow-up. Moreover, few high-quality studies compare long-term cost-effectiveness 8 and the long-term need for revisions, corrections, and donor-site consequences. All of these factors are essential to create evidence-based guidelines, prioritise the usage of healthcare resources and to give the patients information on which they can base decisions of breast reconstruction.…”