Cost-Effectiveness Analysis: Lymph Node Transfer versus Lymphovenous Bypass for Breast Cancer Related Lymphedema
*Yurie Sekigami1, *Sydney Char2, *Cate Mullen1, *Kathryn Huber1, *Yu Cao1, *Rachel Buchsbaum1, Roger Graham1, *Salvatore Nardello3, *Dhruv Singhal4, *Abhishek Chatterjee1
1Tufts Medical Center, Boston, MA;2Tufts University School of Medicine, Boston, MA;3Tufts Community Care, Melrose, MA;4Beth Israel Deaconess Medical Center, Boston, MA
Objective: Lymph node transfer (LNT) and lymphovenous bypass (LVB) are two major surgical options for patients with breast cancer-related lymphedema (BCRL). The objective of our study was to perform a cost-effectiveness analysis comparing LNT and LVB for the treatment of BCRL. Design: Cost-effectiveness analysis. Setting: Private academic hospital. Main Outcome Measure(s): Rates of infection, lymph leak, and failure for each surgery were obtained from literature review. Failure of surgery was defined as the inability to cease conservative therapy postoperatively. Procedural costs were calculated from Medicare reimbursement rates. Cost of conservative management of postoperative surgical site infection and lymph leak, as well as cost of continued decongestive physiotherapy after failed surgery were obtained from literature review. Average utility scores for each health state were obtained via visual analog scale, 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 ($22,464.71 vs $31,916.77) and more effective (31.83 QALY vs 29.24 QALY) than LVB. One-way (deterministic) sensitivity analysis demonstrated that LNT became cost-ineffective when its failure rate was >44.9%. LVB became more cost-effective than LNT when its failure rate was <21.4%. Probabilistic sensitivity analysis using Monte-Carlo simulation demonstrated that even with uncertainty present in the variables analyzed, the majority of simulations (97.5%) favored LNT as the more cost-effective strategy. Conclusion: LNT is a dominant, cost-effective strategy compared to LVB for the treatment of BCRL. 
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