Patient-level costs in margin re-excision for breast-conserving surgery

Background: High rates of reoperation following breast-conserving surgery (BCS) for positive margins are associated with costs to healthcare providers. The aim was to assess the quality of evidence on reported re-excision costs and compare the direct patient-level costs between patients undergoing successful BCS versus reoperations after BCS. Methods: The study used data from women who had BCS with or without reoperation at a single institution between April 2015 and March 2016. A systematic review of health economic analysis in BCS was conducted and scored using the Quality of Health Economic Studies (QHES) instrument. Financial data were retrieved using the Patient-Level Information and Costing Systems (PLICS) for patients. Exchange rates used were: US $1 = 0.75 pound, 1 pound = (sic)1.14 and US $1 = (sic)0.85. Results: The median QHES score was 47 (i.q.r. 32.5-79). Only two of nine studies scored in the upper QHES quartile (score at least 75). Costs of initial lumpectomy and reoperation were in the range US$ 1234-11786 and $655-9136 respectively. Over a 12-month interval, 153 patients had definitive BCS and 59 patients underwent reoperation. The median cost of reoperations after BCS (59 patients) was 4511 pound (range 1752-18019), representing an additional 2136 pound per patient compared with BCS without reoperation (P < 0.001). Conclusion: The systematic review demonstrated variation in methodological approach to cost estimates and a paucity of high-quality cost estimate studies for reoperations. Extrapolating local PLICS data to a national level suggests that getting BCS right first time could result in substantial savings.