Autologous Breast Reconstruction versus Implant-Based Reconstruction: How Do Long-Term Costs and Health Care Use Compare?

Sir: We read with great interest the study by Lemaine et al.1 This study comparatively evaluated the health care use and total costs over 2 years for patients following mastectomy and reconstruction by either implant-based breast reconstruction or autologous breast reconstruction. The findings of the work by Lemaine et al. corroborate our group’s recent meta-analysis, namely, that autologous breast reconstruction may be more cost-effective and yield higher patient-reported outcomes relative to implant-based breast reconstruction.2 Lemaine et al. have recognized important limitations with conducting retrospective studies based on administrative claims data, and we would like to seek clarification regarding their outcome reporting. Their study used 2-year use and cost of care as their primary outcome measures. However, their 2-year use measures are limited to rates of subsequent hospitalizations, emergency room visits, and office visits following initial discharge. We argue that these measures do not serve as a suitable proxy for directly measuring and grading clinical complications. Ideally, for meta-analysis purposes, each separate complication should be reported, such as fat necrosis, flap loss, infection, number of reoperation procedures for complications, and implant-specific complications (including capsular contracture, implant rupture, displacement, deflation, and scarring). In our meta-analysis, we have acknowledged the inconsistency and heterogeneity in clinical outcome reporting. We recommend that all studies should aim to grade clinical complications using accepted outcome tools to enhance their overall quality (e.g., Clavien-Dindo classification for surgical complications, or the Baker classification for capsular contracture severity). These graded clinical outcomes are important determinants for optimally informing management strategies, and failure to report them creates difficulty for practitioners and patients to interpret study findings in the clinical context and for future meta-analyses. Evaluating clinical outcomes is necessary but not sufficient for optimal outcome assessment. Patient-reported outcomes are key to clinical decision-making in this patient cohort, because we know that reconstruction must aim to restore women’s physical, psychological, and sexual well-being following mastectomy. The BREAST-Q is now widely accepted as a suitable and robust patient-reported outcomes tool with which to assess quality of life.3 Regarding cost analysis, Lemaine et al. have compared the longitudinal total costs of autologous breast reconstruction and implant-based breast reconstruction pertaining to professional services in the 2-year follow-up period. However, more robust evaluations of cost-effectiveness require calculation of the incremental cost-effective ratio in conjunction with a breast quality-adjusted life-year: the additional cost for autologous breast reconstruction to obtain 1 year of perfect breast-related quality of life compared with implant-based breast reconstruction. A threshold of $50,000 to $100,000 for 1 year in perfect overall health is deemed acceptable to adopt new technologies or techniques in developed countries.4 Considered together, the evidence weakly supports a role for autologous breast reconstruction as a more cost-effective approach with superior patient-reported outcomes relative to implant-based breast reconstruction. However, higher quality data derived from prospective, international, multicenter studies incorporating standardized outcome measures together with disease-specific patient-reported outcomes tools and cost-efficacy analysis will be essential to optimally inform national and international guidelines and shared decision-making. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication.