BACKGROUND:
Risk assessment evaluation and BRCA testing can occur because a woman considers herself to be at increased risk for developing breast cancer or her physicians, either at routine examination or after diagnosis of unilateral breast cancer, consider her to be at increased risk. This study examined the impact of risk assessment counseling on trends in breast surgery, including both extirpative and reconstructive, and cost.
METHODS:
A retrospective chart review was performed for all women 18 years of age or older who underwent some form of breast surgery for either malignancy or prophylaxis from January 1, 1999 through December 31, 2008 and had at least 1 year follow-up. Study variables include age, presence of and type of breast cancer, stage of breast cancer if present, BRCA 1 or 2 status, family history of breast cancer, length of stay, procedure performed, complications, and cost of procedures (defined as institutional cost, i.e., operating room and facility costs without physician fees).
A total of 301 patients were evaluated to determine the occurrence of unilateral versus bilateral mastectomies in a 4:1 retrospective case-control study. Patients who underwent genetic testing for the BRCA gene mutation and genetic counseling were compared to patients who did not (controls). This study was powered at 70% and α was set at 0.05. All analyses were done using SPSS 15.0 (SPSS Inc, Chicago, IL).
RESULTS:
Counseled patients were more than 7 times as likely to undergo bilateral mastectomies as control patients (OR=8.05 [4. 41, 14.68]). Independent t tests showed a statistically significant difference in overall age, total cost, and variable costs between both groups. Both younger age (46.4 years compared to 61.8, P<0.001) and higher mean total cost ($10,809.91 versus $7265.81) in the counseled group were found to be statistically significant, P<0.001 and P=0.002, respectively.
For both counseled and control groups, younger patients underwent bilateral mastectomies more frequently than older patients and their associated mean total and variable costs were statistically different. In the control group, the mean age of women undergoing bilateral mastectomies was 55.5, whereas those undergoing unilateral mastectomies were aged 63.02 (P=0.004). The cost for unilateral mastectomies was $6176.52 versus $12916.35 for bilateral mastectomies (P<0.001). Similarly, in the counseled group, the mean age of women undergoing bilateral mastectomies was 44.4 years as compared to those undergoing unilateral mastectomies at 49.8 (P=0.014). Again, total costs incurred were less for unilateral ($7717.77) than bilateral ($11,992.20) mastectomies (p=0.050).
Of 55 counseled patients undergoing mastectomy (85 breasts), 78 (92%) breasts were reconstructed, whereas 114 (50%) of 230 breasts were reconstructed in the control group. More counseled women underwent bilateral implant reconstruction than controls (P<0.001). Further, younger women, whether counseled or control group, chose bilateral reconstruction resulting in higher costs (P=0.003 and P<0.001, respectively).
CONCLUSIONS: The combination of BRCA gene testing and genetic counseling has a significant impact upon women such that younger women choose more extensive surgery and reconstruction resulting in increased costs.