Breast Cancer Provides Unique Test For Acceptance of Value-Based Care

When cancer strikes, people want the best treatment. Too often, however, patients equate cost with quality, thinking that pricier treatments offer the best chance of killing the demon, or at least holding it at bay for a few years until reinforcements (breakthrough technologies and treatments) arrive.

Value-based care isn’t on the minds of many people in such situations. That’s the challenge of incorporating such care into oncology, according to a study in the Journal of the National Cancer Institute.

Researchers at the University of Texas MD Anderson Cancer Center noted that in recent years there has been a marked increase in bilateral mastectomy and reconstruction for early breast cancer. “While some of these procedures are clearly medically indicated, the choice for mastectomy is often driven by nonmedical factors such as patient preferences for more ‘complete’ cancer treatment by extirpating the entirety of the affected organ….”

Researchers measured complications within two years of diagnosis. Complications included infection, hematoma/seroma, breast pain, fat necrosis, radiation pneumonitis, rib fracture, graft/implant complication, implant removal, and other postoperative complications.

Cumulative net payer cost within two years of diagnosis was calculated using all inpatient and outpatient claims from within two years of diagnosis. All costs were adjusted to 2014 dollars.

Researchers gathered information about women under age 65 via the MarketScan Commercial Claims and Encounters database. MarketScan provided claims data from 45 large employers and more than 100 health insurance plans.

Data for Medicare beneficiaries came from the National Cancer Institute’s SEER database. The beneficiaries lived in 16 geographic areas.

The study identified 105,211 women (44,344 MarketScan; 60,867 SEER-Medicare) with early breast cancer that was diagnosed between 2000 and 2011.

Lumpectomy plus whole breast irradiation treatment was the most common treatment. But the researchers found that mastectomy plus reconstruction was nearly twice as likely to cause complications than lumpectomy and irradiation treatment (54.3% vs. 29.6% complication risk among younger women with private insurance and 66.1% vs. 37.6% complication risk among older women with Medicare).

In addition, mastectomy plus reconstruction cost more (an average of $22,481 more for younger women; an average of $1,748 more for older women with Medicare) in total costs. There was also a higher cost related to complications (an average of $9,017 greater for the younger cohort; $2,092 greater for the Medicare cohort).

The findings underscore “an important conflict that will be increasingly confronted in an era focused on ‘value’ in health care,” according to the lead author, Benjamin Smith of the University of Texas MD Anderson Cancer Center, and his colleagues. Patients might prefer the more expensive treatment for nonmedical reasons.

“If such a patient is receiving care from a health care entity with a financial stake in promoting ‘high-value’ care, the entity may profit financially if the patient receives the lower-cost intervention and, conversely, may experience a financial loss if the patient receives the higher-cost intervention,” the authors stated.

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