Cost-Effectiveness Analysis: Lymph Node Transfer vs Lymphovenous Bypass for Breast Cancer-Related Lymphedema - 21/05/21

Doi : 10.1016/j.jamcollsurg.2021.02.013

Yurie Sekigami, MD ^a, Sydney Char, BS ^d, Cate Mullen, RN, MSN, AOCNS ^a, Kathryn Huber, MD, PhD ^b, Yu Cao, MD ^b, Rachel Buchsbaum, MD ^c, Roger Graham, MD, FACS ^a, Salvatore Nardello, DO ^e, Dhruv Singhal, MD ^f, Abhishek Chatterjee, MD, MBA, FACS ^a,^⁎
^a Department of Surgery, Tufts Medical Center, Boston, MA
^b Department of Radiation Oncology, Tufts Medical Center, Boston, MA
^c Department of Hematology Oncology, Tufts Medical Center, Boston, MA
^d Tufts University School of Medicine, Boston, MA
^e Department of Surgery, Tufts Medical Center Community Care, Boston, MA
^f Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA

^∗Correspondence address: Abhishek Chatterjee, MD, MBA, FACS, Department of Surgery, Division of Plastic Surgery, South Building, 4^th Floor, 800 Washington St, Box 1043, Boston, MA 02111.Department of SurgeryDivision of Plastic SurgerySouth Building4^th Floor800 Washington StBox 1043BostonMA02111

Abstract

Background

Lymph node transfer (LNT) and lymphovenous bypass (LVB) have been described as 2 major surgical options for patients with breast cancer-related lymphedema (BCRL) who have failed conservative therapy. The objective of our study was to perform a cost-effectiveness analysis comparing LNT and LVB for the treatment of BCRL.

Study design

Rates of infection, lymph leak, and failure of LNT and LVB were obtained from a previously published meta-analysis. Failure of surgery was defined as the inability to cease compression therapy postoperatively. Procedural costs were calculated from Medicare reimbursement rates. Cost of conservative management of postoperative surgical site infection, lymph leak, and continued decongestive physiotherapy after failed surgery were obtained from literature review. Average utility scores for each health state were calculated using a visual analog scale survey, then converted to quality-adjusted life years (QALYs). A decision tree was constructed, and incremental cost-effectiveness ratio was assessed at $50,000/QALY. Deterministic and probabilistic sensitivity analyses were performed to evaluate the robustness of our findings.

Results

LNT was less costly ($22,492 vs $31,927) and more effective (31.82 QALY vs 29.24 QALY) than LVB. One-way (deterministic) sensitivity analysis demonstrated that LNT became cost-ineffective when its failure rate was more than 43.8%. LVB became more cost-effective than LNT when its failure rate was less than 21.4%. Probabilistic sensitivity analysis using Monte-Carlo simulation indicated that even with uncertainty present in the variables analyzed, the majority of simulations (97%) favored LNT as the more cost-effective strategy.

Conclusions: LNT is a dominant, cost-effective strategy compared to LVB for the treatment of BCRL.

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