Article Abstract

Prophylactic mastectomy can save patients up to $50,000 compared to lifelong screening in BRCA 1 and BRCA 2 patients

Authors: Rachel Shirley, Alyssa Pastorino, Danielle Lipoff, Betty Fan, Deepa Halaharvi, Mark Cripe


Background: Awareness of value-based, quality carehas become an increasingly important issue for healthcare. Patients with a BRCAmutation have a lifetime risk of developing breast cancer up to 87% by age 70.The option of high-risk screening versus risk-reducing surgery is a physical,emotional, and financial decision. Given the significant expense associatedwith lifetime screening for BRCA 1 and 2 patients, surgery may not only be anoption to prevent cancer but may reduce healthcare cost as well. To date thereare no cost analysis of surgery versus screening from the patient perspective.We designed a study to compare the expense of lifelong screening versusprophylactic mastectomy with reconstruction for BRCA 1 and 2 patients toevaluate potential cost-saving benefits.
Methods: We performed a projected cost analysisbased the on an estimate of lifelong, high-risk screening compared toprophylactic bilateral mastectomy with deep inferior epigastric perforator(DIEP) flap reconstruction. We utilized National Comprehensive Cancer Network(NCCN) recommendations to define lifelong high-risk breast screening. Thescreening included the cost of 1 additional office visit per year, an annualbreast magnetic resonance image (MRI), and an annual mammogram. Costs werecalculated from average expenses charged to patients as well estimates from thebilling hotline at our institution. The final estimates are after all discountshave been taken by the hospital and are representative of the final out ofpocket fee that is paid. The high-risk screening cost was compared to the cost ofa bilateral prophylactic mastectomy with DIEP flap reconstruction. Included inthis surgery cost was the operating room fees, plastic surgeon fees, anesthesiafees, and the hospital stay. The patient costs were estimated based on ahypothetical insurance plan with a deductible of $1,000 ,an 80/20 copay, and a$5,000 annual out of pocket maximum.
Results: When comparing the totalexpenditures, we found that the estimated annual cost for screening is $2,611.The patient out of pocket cost is then calculated to be $1,322 annually. Thusif a patient has no events, biopsies, or cancers, high-risk screening will costan estimated $67,422 over the patient’s lifetime. The insurance company willpay an estimated $1,405/year with a lifetime total of $71,075. The totallifetime screening cost is $138,497 paid by both the patient and insurancecompany. The bilateral prophylactic mastectomy with DIEP reconstruction costaverage reimbursement was $94,733. Of this cost, the patient will pay her outof pocket maximum for the year, but will not have further charges associatedwith high-risk screening. If an insurance plan has an out of pocket maximum of$5,000 the patient has the potential of a lifetime savings of $62,422 with theadded benefit of a significant cancer risk-reduction. Additionally as the totalout of pocket for the patient is additive, it is most financially beneficialfor the patient to have surgery at a younger age. The insurance provider pays$71,075 for screening and $89,733 for prophylactic surgery. Although theinsurance provide ultimately pays more for surgery in this model, the benefitis in the reduction of cancer and its associated costs.
Conclusions: Patients with a BRCA mutation will save morethan $50,000 over their lifetimes by choosing to undergo early risk-reducingprophylactic mastectomy with reconstruction. Therefore the surgery option notonly reduces cancer risk, but also has a significant lifetime cost savings.Patient cost perspectives have not previously been published and we feel that’swhat makes this novel and an asset to future patient conversations.