Combining vascularized lymph node transfer with autologous breast reconstruction: A Surveillance, Epidemiology and End Results (SEER) Database cost-utility analysis

Background: The cost effectiveness of combining vascularized lymph node transfer (VLNT) with autologous breast reconstruction has not been established. Herein we describe the use of Markov modeling to evaluate the cost utility of VLNT with delayed autologous breast reconstruction for patients with breast cancer related lymphedema (BCRL). Methods: We conducted a cost effectiveness analysis using a Markov model with microsimulation. The characteristics and associated life expectancy of the hypothetical patients were derived from the Surveillance, Epidemiology, and End Results database. Costs of were derived from the publicly available sources and health economics literature. The utilities were based on the best available literature. The relative effectiveness of VLNT was derived from a meta-analysis of the literature. A specific strategy is considered attractive if the estimate of incremental cost effectiveness ratio (ICER) is less than the amount decision makers are willing to pay for an additional quality-adjusted life-year (QALY) gain. A baseline willingness to pay of $50,000 USD per additional QALY was used for analysis. Results: The base case situation demonstrated an overall ICER of $13898.76/QALY for adding VLNT to delayed autologous abdominally based breast reconstruction in the situation where lymphedema is already present, which suggests it is cost-effective at the chosen willingness to pay. Discussion: This cost-utility simulation demonstrates that it is cost effective to combine delayed breast reconstruction with VLNT in patients with existing lymphedema. This could have implications for the application of the evolving technique of VLNT in the treatment of different subpopulations of breast cancer patients, and future clinical research. (C) 2020 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.