Cost-Benefit Analysis of Intraoperative Diagnosis of Axillary Sentinel Lymph Nodes in Breast Cancer Patients.
Hope T Richard, Dana L Johnson, Celeste N Powers, Michael O Idowu. Virginia Commonwealth University, Richmond
Background: Cost containment is critical in the current healthcare era. False negative(FN) intraoperative interpretation of sentinel lymph nodes(SLN) often leads to a delayed axillary dissection with additional costs. While it has been reported that there is no increase in morbidity between immediate and delayed axillary dissection, information regarding cost-benefit analysis for intraoperative SLN assessment is limited. This study evaluates the estimated potential savings associated with true positive(TP) SLN versus the additional costs of subsequent intervention for FN diagnoses.
Design: We reviewed all SLN received for intraoperative evaluation on patients with invasive breast carcinoma undergoing initial partial or total mastectomy between 1999 and 2010. Sentinel lymph nodes in DCIS cases were excluded. FN and TP rates were calculated based on correlation with permanent section. Surgical costs were estimated based on total billing per procedure for a representative patient population. Collateral cost associated with chemotherapy, radiotherapy and lost wages due to hospitalization were not included.
Results: 982 cases, with a median number of 2 LN/case, were reviewed. 11% (n=108) of the cases had FN SLN; 53% (n=57) underwent delayed axillary dissection 3-4 weeks following the initial surgery, while 47% (n=51) of FN cases had micrometastasis (2mm-0.2mm) or isolated tumor cells (<0.2mm) and did not undergo completion axillary dissection. Patients with TP SLN underwent immediate axillary dissection with no need for subsequent surgical intervention. The average cost per patient of initial resection with or without axillary dissection was $32,239. On average, delayed axillary dissection led to an additional charge of $19,120 per patient, which introduces an overall additional cost of $1,089,840. However, the estimated cost savings associated with TP SLN was found to be $3,193,040, leading to an overall savings of $2,103,200 associated with correct intraoperative SLN interpretation.
|# of cases||Procedure||Cost savings||Additional costs|
|True Positive||167(17%)||Immediate axillary dissection||$3,193,040||$0|
|False Negative||108(11%)||Delayed axillary dissection (n=57)||$0||$1,089,840|
|False Positive||4(0.4%)||Immediate axillary dissection||$0||$0|
|True Negative||703(72%)||No additional surgery||$0||$0|