Systematic review of cost-effectiveness in breast reconstruction: deep inferior epigastric perforator flap vs. implant-based breast reconstruction
DOI:
https://doi.org/10.2340/jphs.v59.19649Keywords:
Health economics, breast reconstruction, plastic surgery, ICER, cost-effectiveness, prioritizingAbstract
Background: There are several techniques for reconstructing breasts after mastectomy, but little scientific evidence for which technique is superior. The aim of this systematic review was to compare the cost-effectiveness of implant-based and autologous reconstruction and to evaluate the overall certainty of evidence, as well as the quality of reporting of the included studies.
Methods: Studies investigating the cost-effectiveness of breast reconstruction with a deep inferior epigastric perforator (DIEP) flap compared to implant-based reconstruction, meeting criteria defined in a PICO (population, intervention, comparison, and outcome), were included. Medline, PubMed, Embase, Cochrane library, CinahL, EconLit, and NHS EED databases were searched. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess the certainty of evidence, and the Consolidated Health Economic Evaluation Reporting Standard (CHEERS) 2022 was used to evaluate the quality of reporting.
Results and conclusions: A total of 256 abstracts were retrieved from the search, and after scrutiny, seven studies were included. The findings of this present systematic review should be interpreted with caution as the overall certainty of evidence is low (GRADE ƟƟОО). The included studies suggest that DIEP-flaps are cost-effective compared with implant-based breast reconstruction when the applied cost-effectiveness thresholds of $50,000 to $100,000 per quality-adjusted life years are used. It is noteworthy that no high level evidence exists regarding cost-effeciency, to support recommendations and decision in breast reconstruction. Methodological issues that can be improved in future studies are presented.
Downloads
References
Giunta RE, Hansson E, Andresen C, et al. ESPRAS survey on breast reconstruction in Europe. Handchir Mikrochir Plast Chir. 2021;53(4):340–348. https://doi.org/10.1055/a-1424-1428 DOI: https://doi.org/10.1055/a-1424-1428
Potter S, Holcombe C, Ward JA, et al. Development of a core outcome set for research and audit studies in reconstructive breast surgery. Br J Surg. 2015;102(11):1360–1371. https://doi.org/10.1002/bjs.9883 DOI: https://doi.org/10.1002/bjs.9883
Tessler O, Mattos D, Vorstenbosch J, et al. A methodological analysis of the plastic surgery cost-utility literature using established guidelines. Plast Reconstr Surg. 2014;133(4):584e–592e. https://doi.org/10.1097/PRS.0000000000000004 DOI: https://doi.org/10.1097/PRS.0000000000000004
Khajuria A, Prokopenko M, Greenfield M, et al. A meta-analysis of clinical, patient-reported outcomes and cost of DIEP versus implant-based breast reconstruction. Plast Reconstr Surg Glob Open. 2019;7(10):e2486. https://doi.org/10.1097/GOX.0000000000002486 DOI: https://doi.org/10.1097/GOX.0000000000002486
Atherton DD, Hills AJ, Moradi P, et al. The economic viability of breast reconstruction in the UK: comparison of a single surgeon’s experience of implant; LD; TRAM and DIEP based reconstructions in 274 patients. J Plast Reconstr Aesthet Surg. 2011;64(6):710–715. https://doi.org/10.1016/j.bjps.2010.11.001 DOI: https://doi.org/10.1016/j.bjps.2010.11.001
Damen THC, Wei W, Mureau MAM, et al. Medium-term cost analysis of breast reconstructions in a single Dutch centre: a comparison of implants, implants preceded by tissue expansion, LD transpositions and DIEP flaps. J Plast Reconstr Aesthet Surg. 2011;64(8):1043–1055. https://doi.org/10.1016/j.bjps.2010.12.028 DOI: https://doi.org/10.1016/j.bjps.2010.12.028
Lagares-Borrego A, Gacto-Sanchez P, Infante-Cossio P, et al. A comparison of long-term cost and clinical outcomes between the two-stage sequence expander/prosthesis and autologous deep inferior epigastric flap methods for breast reconstruction in a public hospital. J Plast Reconstr and Aesthet Surg. 2016;69(2):196–205. https://doi.org/10.1016/j.bjps.2015.11.027 DOI: https://doi.org/10.1016/j.bjps.2015.11.027
Neyt MJ, Blondeel PN, Morrison CM, et al. Comparing the cost of delayed and immediate autologous breast reconstruction in Belgium. Br J Plast Surg. 2005;58(4):493–497. https://doi.org/10.1016/j.bjps.2004.12.002 DOI: https://doi.org/10.1016/j.bjps.2004.12.002
Palve JS, Luukkaala TH, Kääriäinen MT. Autologous reconstructions are associated with greater overall medium-term care costs than implant-based reconstructions in the Finnish healthcare system: a retrospective interim case-control cohort study. J Plast Reconstr Aesthet Surg. 2022;75(1):85–93. https://doi.org/10.1016/j.bjps.2021.08.020 DOI: https://doi.org/10.1016/j.bjps.2021.08.020
Tran BNN, Fadayomi A, Lin SJ, et al. Cost analysis of postmastectomy reconstruction: a comparison of two staged implant reconstruction using tissue expander and acellular dermal matrix with abdominal-based perforator free flaps. J Surg Oncol. 2017;116(4):439–447. https://doi.org/10.1002/jso.24692 DOI: https://doi.org/10.1002/jso.24692
Phan R, Hunter-Smith DJ, Rozen WM. The use of patient reported outcome measures in assessing patient outcomes when comparing autologous to alloplastic breast reconstruction: a systematic review. Gland Surg. 2019;8(4):452–460. https://doi.org/10.21037/gs.2019.07.04 DOI: https://doi.org/10.21037/gs.2019.07.04
Eltahir Y, Krabbe-Timmerman IS, Sadok N, et al. Outcome of quality of life for women undergoing autologous versus alloplastic breast reconstruction following mastectomy: a systematic review and meta-analysis. Plast Reconstr Surg. 2020;145(5):1109–1123. https://doi.org/10.1097/PRS.0000000000006720 DOI: https://doi.org/10.1097/PRS.0000000000006720
Toyserkani NM, Jorgensen MG, Tabatabaeifar S, et al. Autologous versus implant-based breast reconstruction: a systematic review and meta-analysis of breast-Q patient-reported outcomes. J Plast Reconstr Aesthet Surg. 2020;73(2):278–285. https://doi.org/10.1016/j.bjps.2019.09.040 DOI: https://doi.org/10.1016/j.bjps.2019.09.040
Drummond MF, Sculpher MJ, Claxton K, et al. Methods for the economic evaluation of health care programmes. Oxford: Oxford University Press; 2015.
Honkanen N, Mustonen L, Kalso E, et al. Breast reconstruction after breast cancer surgery – persistent pain and quality of life 1–8 years after breast reconstruction. Scand J Pain. 2021;21(3):522–529. https://doi.org/10.1515/sjpain-2021-0026 DOI: https://doi.org/10.1515/sjpain-2021-0026
Eltahir Y, Werners L, Dreise MM, et al. Quality-of-life outcomes between mastectomy alone and breast reconstruction: comparison of patient-reported BREAST-Q and other health-related quality-of-life measures. Plast Reconstr Surg. 2013;132(2):201e–209e. https://doi.org/10.1097/PRS.0b013e31829586a7 DOI: https://doi.org/10.1097/PRS.0b013e31829586a7
Thoma A, Avram R, Dal Cin A, et al. Cost-effectiveness analysis of abdominal-based autogenous tissue and tissue-expander implant following mastectomy. Plast Reconstr Surg Glob Open. 2020;8(10):e2986. https://doi.org/10.1097/GOX.0000000000002986 DOI: https://doi.org/10.1097/GOX.0000000000002986
Kouwenberg CAE, Kranenburg LW, Visser MS, et al. The validity of the EQ-5D-5L in measuring quality of life benefits of breast reconstruction. J Plast Reconstr Aesthet Surg. 2019;72(1):52–61. https://doi.org/10.1016/j.bjps.2018.08.023 DOI: https://doi.org/10.1016/j.bjps.2018.08.023
Sinno H, Dionisopoulos T, Slavin SA, et al. The utility of outcome studies in plastic surgery. Plast Reconstr Surg Glob Open. 2014;2(7):e189. https://doi.org/10.1097/GOX.0000000000000104 DOI: https://doi.org/10.1097/GOX.0000000000000104
Thoma A, McKnight LL. Quality-adjusted life-year as a surgical outcome measure: a primer for plastic surgeons. Plast Reconstr Surg. 2010;125(4):1279–1287. https://doi.org/10.1097/PRS.0b013e3181d0ae58 DOI: https://doi.org/10.1097/PRS.0b013e3181d0ae58
Sheckter CC, Matros E, Momeni A. Assessing value in breast reconstruction: a systematic review of cost-effectiveness studies. J Plast Reconstr Aesthet Surg. 2018;71(3):353–365. https://doi.org/10.1016/j.bjps.2017.09.010 DOI: https://doi.org/10.1016/j.bjps.2017.09.010
Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336(7650):924–926. https://doi.org/10.1136/bmj.39489.470347.AD DOI: https://doi.org/10.1136/bmj.39489.470347.AD
Moher D, Shamseer L, Clarke M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev. 2015;4:1. https://doi.org/10.1186/2046-4053-4-1 DOI: https://doi.org/10.1186/2046-4053-4-1
Brunetti M, Shemilt I, Pregno S, et al. GRADE guidelines: 10. Considering resource use and rating the quality of economic evidence. J Clin Epidemiol. 2013;66(2):140–150. https://doi.org/10.1016/j.jclinepi.2012.04.012 DOI: https://doi.org/10.1016/j.jclinepi.2012.04.012
Brozek JL, Canelo-Aybar C, Akl EA, et al. GRADE guidelines 30: the GRADE approach to assessing the certainty of modeled evidence – an overview in the context of health decision-making. J Clin Epidemiol. 2021;129:138–150. https://doi.org/10.1016/j.jclinepi.2020.09.018 DOI: https://doi.org/10.1016/j.jclinepi.2020.09.018
Schünemann H, Brożek J, Guyatt G, et al. GRADE handbook. The GRADE working group. 2013. https://gdt.gradepro.org/app/handbook/handbook.html
Husereau D, Drummond M, Augustovski F, et al. Consolidated health economic evaluation reporting standards 2022 (CHEERS 2022) statement: updated reporting guidance for health economic evaluations. BMJ. 2022;376:e067975. https://doi.org/10.1136/bmj-2021-067975 DOI: https://doi.org/10.1136/bmj-2021-067975
Bloom JA, Shah SA, Long EA, et al. Post-mastectomy tissue expander placement followed by radiation therapy: a cost-effectiveness analysis of staged autologous versus implant-based unilateral reconstruction. Ann Surg Oncol. 2023;30(2):1075–1083. https://doi.org/10.1245/s10434-022-12619-5 DOI: https://doi.org/10.1245/s10434-022-12619-5
Razdan SN, Cordeiro PG, Albornoz CR, et al. Cost-effectiveness analysis of breast reconstruction options in the setting of postmastectomy radiotherapy using the BREAST-Q. Plast Reconstr Surg. 2016;137(3):510e–517e. https://doi.org/10.1097/01.prs.0000479935.92904.a3 DOI: https://doi.org/10.1097/01.prs.0000479935.92904.a3
Grover R, Padula WV, Van Vliet M, et al. Comparing five alternative methods of breast reconstruction surgery: a cost-effectiveness analysis. Plast Reconstr Surg. 2013;132(5):709e–723e. https://doi.org/10.1097/PRS.0b013e3182a48b10 DOI: https://doi.org/10.1097/PRS.0b013e3182a48b10
Klifto KM, Tecce MG, Serletti JM, et al. Comparison of nine methods of immediate breast reconstruction after resection of localized breast cancer: a cost-effectiveness Markov decision analysis of prospective studies. Microsurgery. 2022;42(5):401–427. https://doi.org/10.1002/micr.30882 DOI: https://doi.org/10.1002/micr.30882
Matros E, Albornoz CR, Razdan SN, et al. Cost-effectiveness analysis of implants versus autologous perforator flaps using the BREAST-Q. Plast Reconstr Surg. 2015;135(4):937–946. https://doi.org/10.1097/PRS.0000000000001134 DOI: https://doi.org/10.1097/PRS.0000000000001134
Kouwenberg CAE, Mureau MAM, Kranenburg LW, et al. Cost-utility analysis of four common surgical treatment pathways for breast cancer. Eur J Surg Oncol. 2021;47(6):1299–1308. https://doi.org/10.1016/j.ejso.2020.11.130 DOI: https://doi.org/10.1016/j.ejso.2020.11.130
Thoma A, Avram R, Dal Cin A, et al. Comparing the clinical and cost-effectiveness of abdominal-based autogenous tissue and tissue-expander implant: a feasibility study. Plast Reconstr Surg Glob Open. 2020;8(10):e3179. https://doi.org/10.1097/GOX.0000000000003179 DOI: https://doi.org/10.1097/GOX.0000000000003179
Klifto KM, Christopher A, Morris M, et al. Cost-effectiveness of nine methods of immediate breast reconstruction for women with localized breast cancer not receiving radiation therapy: a Markov/Monte Carlo analysis. J Am Coll Surg. 2021;233(5):s34. https://doi.org/10.1016/j.jamcollsurg.2021.07.045 DOI: https://doi.org/10.1016/j.jamcollsurg.2021.07.045
Kouwenberg CAE, de Ligt KM, Kranenburg LW, et al. Long-term health-related quality of life after four common surgical treatment options for breast cancer and the effect of complications: a retrospective patient-reported survey among 1871 patients. Plast Reconstr Surg. 2020;146(1):1–13. https://doi.org/10.1097/PRS.0000000000006887 DOI: https://doi.org/10.1097/PRS.0000000000006887
Hansson E, Sandman L, Davidson T. A systematic review of direct preference measurements in health states treated with plastic surgery. J Plast Surg Hand Surg. 2022;56(3):180–190. https://doi.org/10.1080/2000656X.2021.1953039 DOI: https://doi.org/10.1080/2000656X.2021.1953039
Brorson F, Elander A, Thorarinsson A, et al. Patient reported outcome and quality of life after delayed breast reconstruction – an RCT comparing different reconstructive methods in radiated and non-radiated patients. Clin Breast Cancer. 2022;22(8):753–761. https://doi.org/10.1016/j.clbc.2022.09.004 DOI: https://doi.org/10.1016/j.clbc.2022.09.004
Parikh RP, Sharma K, Qureshi AA, et al. Quality of surgical outcomes reporting in plastic surgery: a 15-year analysis of complication data. Plast Reconstr Surg. 2018;141(6):1332–1340. https://doi.org/10.1097/PRS.0000000000004362 DOI: https://doi.org/10.1097/PRS.0000000000004362
Åhlin E (ed). Cancer i siffror 2023. The Swedish National Board of Social Affairs and Health Care and The Swedish Cancer Association. 2023. Stockholm. https://static-files.cancerfonden.se/Cancer-i-siffror-2023.pdf
Levine SM, Lester ME, Fontenot B, et al. Perforator flap breast reconstruction after unsatisfactory implant reconstruction. Ann Plast Surg. 2011;66(5):513–517. https://doi.org/10.1097/SAP.0b013e3182012597 DOI: https://doi.org/10.1097/SAP.0b013e3182012597
Roostaeian J, Yoon AP, Ordon S, et al. Impact of prior tissue expander/implant on postmastectomy free flap breast reconstruction. Plast Reconstr Surg. 2016;137(4):1083–1091. https://doi.org/10.1097/01.prs.0000481044.61991.6b DOI: https://doi.org/10.1097/01.prs.0000481044.61991.6b
Versteegh M, Knies S, Brouwer W. From good to better: new Dutch guidelines for economic evaluations in healthcare. Pharmacoeconomics. 2016;34(11):1071–1074. https://doi.org/10.1007/s40273-016-0431-y DOI: https://doi.org/10.1007/s40273-016-0431-y
Longworth L, Yang Y, Young T, et al. Use of generic and condition-specific measures of health-related quality of life in NICE decision-making: a systematic review, statistical modelling and survey. Health Technol Assess. 2014;18(9):1–224. https://doi.org/10.3310/hta18090 DOI: https://doi.org/10.3310/hta18090
Whittal A, Meregaglia M, Nicod E. The use of patient-reported outcome measures in rare diseases and implications for health technology assessment. Patient. 2021;14(5):485–503. https://doi.org/10.1007/s40271-020-00493-w DOI: https://doi.org/10.1007/s40271-020-00493-w
Sadok N, Refaee MS, Eltahir Y, et al. Quality of life 9 to 13 years after autologous or alloplastic breast reconstruction: which breast remains best? Plast Reconstr Surg. 2023;151(3):467–476. https://doi.org/10.1097/PRS.0000000000009899 DOI: https://doi.org/10.1097/PRS.0000000000009899
U.S. Department of Labour. The Women’s Health and Cancer Rights Act (WHCRA). Whashington DC, USA; 1998. https://www.dol.gov/sites/default/files/ebsa/about-ebsa/our-activities/resource-center/publications/cagwhcra.pdf
The New York State Senate. The New York State (NYS) Breast Cancer Provider Discussion Law. Bill S.6993-B. New York, USA; 2010. https://legislation.nysenate.gov/pdf/bills/2009/S6993B The European Parliament. European Parliament resolution on breast cancer in the European Union (2002/2279(INI)). Brussels, Belgium; 2002.
http://www.europarl.europa.eu/sides/getDoc.do?pubRef=-//EP//TEXT+TA+P5-TA-2003-0270+0+DOC+XML+V0//EN
Endara MR, Verma K, Nahabedian MY. Tertiary breast reconstruction using a free contralateral latissimus dorsi musculocutaneous flap. J Reconstr Microsurg. 2014;30(2):141–143. https://doi.org/10.1055/s-0033-1354743 DOI: https://doi.org/10.1055/s-0033-1354743
Higgins KS, Gillis J, Williams JG, et al. Women’s experiences with flap failure after autologous breast reconstruction: a qualitative analysis. Ann Plast Surg. 2017;78(5):521–525. https://doi.org/10.1097/SAP.0000000000000910 DOI: https://doi.org/10.1097/SAP.0000000000000910
Mahoney B, Walklet E, Bradley E, et al. Experiences of implant loss after immediate implant-based breast reconstruction: qualitative study. BJS Open. 2020;4(3):380–390. https://doi.org/10.1002/bjs5.50275 DOI: https://doi.org/10.1002/bjs5.50275
Additional Files
Published
How to Cite
Issue
Section
License
Copyright (c) 2024 Emma Hansson, Fredrik Brorson, Jonas Löfstrand, Anna Elander, Mikael Svensson
This work is licensed under a Creative Commons Attribution 4.0 International License.
Acta Chirurgica Scandinavica Society owns the copyright for all material published until Volume 57 (2023) unless otherwise specified. As from Volume 59 (2024) all published articles, unless otherwise specified, are published under CC-BY licences, allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material for non-commercial purposes, provided proper attribution to the original work.
