What Influence Do Treatment Costs Have on Breast Cancer Surgery Preferences?

When deciding about surgery for breast cancer, women, especially those with a lower household income, factored cost of treatment into their decision, according to a study reported in the Journal of Oncology Practice.

Julie Nangia, MD, an assistant professor of medicine at the Lester and Sue Breast Center at Baylor College of Medicine, Houston, told Cancer Network that the overall findings didn’t surprise her. She explained that cost makes a big difference in breast cancer patients’ decisions and that she has seen this in her patients for many years.

“Now you have the data to show that it is true,” she said.

To investigate whether treatment costs were a consideration, study researchers sent an online 88-item questionnaire to women who had been previously diagnosed with stage 0 to III breast cancer. All women included in the study were from the Dr. Susan Love Research Foundation’s Army of Women and the Sisters Network of North Carolina.

The questionnaire asked about treatment costs and surgical decision-making. It included questions about how the treatment costs compared with other factors often taken into account when making a decision about surgery. For example, a patient may consider recovery time, possible surgical complications, and breast appearance.

The analysis included 607 women, the majority of whom (85.7%) had stage 0, I, or II disease at the time of diagnosis. The study population had a median age of 49.6 years (range, 26­­­­–76 years), and a median time from diagnosis of 6.7 years (0.1–37.1 years). Most of the women were white (90%), college educated (78%), and had either private insurance (70%) or Medicare (25%). More than half (56%) of the participants had household incomes of more than $74,000.

Overall, 43% of women chose breast-conserving surgery, 25% chose mastectomy, 32% chose bilateral mastectomy, and 36% chose breast reconstruction.

The survey responses revealed that 43% of women considered costs when making treatment decisions about their breast cancer surgery, and 28% of women reported that treatment costs influenced their decisions for breast cancer surgery. The importance of costs was higher among patients with lower household incomes compared with higher household incomes.

For women in the lowest household income bracket, bringing in $45,000 or less per year, cost had more influence on surgery decisions than other considerations, including loss of sensation, breast preservation or appearance, requirement for long-term surveillance, and forgoing of radiation. In addition, a quarter of these low-income women avoided doctors and medical testing and 29% had difficulty paying for basic necessities.

The survey also showed that 16% of women with a household income of more than $125,000 per year reported that costs were somewhat to extremely important. In addition, a proportion of patients belonging to all income brackets drained savings as a result of breast cancer treatment: $45,000 or more (39%), $45,000 to $74,000 (23%), and $74,000 to $125,000 (18%).

“Healthcare is really expensive,” said Nangia. “No matter your income.”

The study researchers reported that while 28% of women considered cancer treatment costs as at least somewhat important to their surgical decision, 78% reportedly never talked about treatment costs with their cancer team.

Nangia said that this statistic may be misleading, explaining that in her experience typically the patient discusses cost of treatment with the financial offices of the institution and a cost estimate is provided before surgery.

“I don’t know if a lot of people consider the financial office part of their care team,” she said.