Discussion: The Cost of Contralateral Prophylactic Mastectomy in Women with Unilateral Breast Cancer

Plastic surgeons are central to the debate on contralateral prophylactic mastectomy. Although national rates of breast reconstruction following unilateral mastectomy are approximately 40 percent, greater than 80 percent of women who choose a double mastectomy will undergo reconstruction.^1,2 Thus, for a patient considering contralateral prophylactic mastectomy, reconstruction is linked to the decision-making process.³ In a well-executed study using an insurance claims database, Momoh and colleagues demonstrated that, over 18 months postoperatively, the receipt of contralateral prophylactic mastectomy was predictive of a higher adjusted mean difference in cumulative cost of $11,872 compared with unilateral mastectomy.⁴ Although the findings are intuitive (i.e., surgery of two sides with reconstruction costs more than surgery of one side), the authors’ underlying intent is likely to raise reader awareness of greater questions surrounding contralateral prophylactic mastectomy.

Should we be performing contralateral prophylactic mastectomy? It depends on whose viewpoint you adopt. From the position of the medical and surgical oncologist whose primary aim is to cure cancer, because no clear survival advantage has been demonstrated with contralateral prophylactic mastectomy, this would appear to be a nonindicated procedure, serving only to increase complication rates. However, this may not capture the patient-centric viewpoint advocated by the Institute of Medicine.⁵ For example, patients have an additional set of concerns, including the desire to avoid future cancer episodes, the need for ongoing surveillance, and the lack of asymmetry often associated with unilateral prosthetic reconstruction.⁶ Patient-reported outcomes data show greater rates of satisfaction with breasts for bilateral compared with unilateral prosthetic reconstruction along with reduced anxiety compared with preoperative levels.⁷ As physicians who enhance quality (not necessarily quantity) of life, perhaps plastic surgeons are uniquely positioned to understand both viewpoints on the matter. Regardless, contralateral prophylactic mastectomy underscores the ongoing need for a shared decision-making process between patients and practitioners, as high-quality outcomes can only be achieved when there is a frank dialogue among all parties about risks, benefits, and longterm goals.

Who pays for it? Health insurance is based on the concept of shared risk pools wherein a range of both healthy and sick patients is required. The presence of a number of healthy enrollees ensures that adequate funds are available to pay for those who get sick. When a patient chooses to undergo contralateral prophylactic mastectomy, the increased cost of this procedure, as demonstrated in the current report by Momoh et al., is absorbed by the medical system.⁴ To cover the greater expenditures, the insurance company passes these costs on to the consumer in the form of greater premiums. Thus, our entire society pays for this procedure, albeit indirectly. With health care costs spiraling upward in the United States in the current fee-for-service environment, whether or not we can support such procedures will definitely be an ongoing source of debate, and some have already suggested we should not.⁸ However, given the privileged position plastic surgeons have as proponents of health-related quality of life, our discipline should remain actively engaged in this topic as it evolves. Lastly, the impact health policy and insurance can have on rates of contralateral prophylactic mastectomy is profound. Budget-constrained environments, such as the United Kingdom, where health care expenditures represent a significantly lower proportion of gross domestic product, do not freely provide payment for contralateral prophylactic mastectomy, citing an absence of a survival benefit.⁹ As such, in the United Kingdom, contralateral prophylactic mastectomy rates are only 3.1 percent.¹⁰ Therefore, any legislative or insurance changes in the United States should be carefully evaluated as to the potential impact on contralateral prophylactic mastectomy.