Beyond the Margins—Economic Costs and Complications Associated With Repeated Breast-Conserving Surgeries

For early stage breast cancer, breast-conserving surgery (BCS) is a compelling alternative to mastectomy, resulting in lower complication rates,¹ equivalent patient-reported quality of life and cosmesis,² and equivalent or better survival rates.³ Unfortunately, these benefits may not be fully realized in women who undergo repeated surgery, usually to increase the resection margin.⁴ Although considerable attention has been drawn to this problem, the costs and complications resulting from additional operations are not well-characterized. Herein we present a retrospective review of insurance claims data for BCS patients performed to assess clinical complications and economic outcomes.

Private claims data were analyzed for 9837 women undergoing BCS for recently diagnosed breast carcinoma between January 2010 and December 2013 (continuous 2-year private insurance enrollment in Illinois, Texas, New Mexico, and Oklahoma; initial BCS identified via the codes in Table 1; diagnosis was any International Classification of Diseases, Ninth Revision [ICD-9] diagnosis code 174.0 through 174.9 within 60 days). Patients undergoing a second open breast surgery (mastectomy or BCS) within 90 days of the initial BCS were classified as having a repeated surgery (Table 1). Complications were identified via a set of 8 Current Procedural Terminology (CPT) and 25 ICD-9 diagnosis and procedure codes (Table 1). The analysis included these complications and the total cost of all allowed health care claims, related and unrelated to breast cancer care, within 2 years following diagnosis. Statistical significance values were calculated for complications via a χ²test with a 2-tailed P value and for costs via 95% CIs. The study was exempt from institutional review board approval and patient informed consent because all data used were deidentified.

Among 9837 women, mean age 53 years, 2282 women (23.2%; 95% CI, 22.4%-24.0%) underwent at least 1 additional breast operation (Table 2). Women who underwent an additional operation waited an average of 24 days for the second procedure. The mean cost for a patient undergoing any repeated surgery was $16 072 higher, and 56.4% of those added costs were incurred within 6 months after the initial BCS. The mean 2-year total health care costs increased by $11 621 for patients undergoing a repeated BCS and $26 276 for patients undergoing a subsequent mastectomy. Increased costs owing to a repeated surgery were statistically significant (mean, $89 016; 95% CI, $87 132-$90 899 without an additional surgery vs mean, $105 088; 95% CI, $101 408-$108 768 with a repeated surgery; P <.001).

For women undergoing a repeated surgery, the likelihood of experiencing at least 1 complication was 47.6% higher (relative, 11.2%; absolute, 34.8%; 95% CI, 32.9%-36.7% vs 23.6%; 95% CI, 22.6%-24.6%) and the likelihood of experiencing multiple complications was 89.1% higher (relative, 4.9%; absolute, 5.5%; 95% CI, 5.0%-6.0% vs 10.4%; 95% CI, 9.1%-11.7%) than for patients undergoing a single BCS. For patients undergoing a repeated surgery, infection, hematoma and/or seroma, and fat necrosis were the most common complications. In the 3 months following the initial BCS, complications were twice as likely in patients undergoing a repeated breast surgery (16.2%; 95% CI, 14.7%-17.7% vs 7.9%; 95% CI, 7.3%-8.5%; P < .001). Increased complications owing to a repeated surgery were statistically significant.

These data demonstrate that in 23.2% of BCS patients, the full benefits of BCS are not realized owing to the added costs and complications of subsequent surgery. For example, mastectomy is associated with a 15.7% 2-year infection rate,⁴ which is similar to the 15.3% experienced by repeated-surgery patients. Patients undergoing additional surgeries incur an average $16 072 in added health care costs. Indeed, reexcision after BCS owing to margin status has been deemed “the other breast cancer epidemic.”⁵ Notably, the data in this work preceded the recent SSO-ASTRO margin guidelines, which may impact future repeated surgery rates. Although many women will continue to benefit from BCS, these findings demonstrate quantitative evidence of a patient-centered and fiscal requirement to implement techniques to reduce BCS reoperations, including advanced margin evaluation.⁶

Corresponding Author: Adam M. Zysk, PhD, 222 Merchandise Mart Plaza, Ste 1230, Chicago, IL 60654 (azysk@diagnosticphotonics.com).

Accepted for Publication: May 3, 2017.

Published Online: August 2, 2017. doi:10.1001/jamasurg.2017.2661

Author Contributions: Drs Metcalf and Zysk had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Metcalfe, Zysk, Jacobs, Oker, Thompson.

Acquisition, analysis, or interpretation of data: Metcalfe, Zysk, Yemul, Underwood, Thompson.

Drafting of the manuscript: Zysk, Yemul, Underwood.

Critical revision of the manuscript for important intellectual content: Metcalfe, Zysk, Jacobs, Oker, Thompson.

Statistical analysis: Metcalfe, Zysk, Yemul.

Administrative, technical, or material support: Yemul.

Supervision: Metcalfe, Oker, Underwood, Thompson.

Conflict of Interest Disclosures: Dr Zysk and Ms Yemul are employees of and hold stock options in Diagnostic Photonics, Inc. Dr Zysk, Ms Yemul, and Dr Jacobs receive salary support via grant R44CA165436 from the National Institutes of Health, National Cancer Institute. Dr Underwood holds stock in Aetna, Inc. No other disclosures were reported.