Patient characteristics in the matched and unmatched groups are summarized in Table 1. Patients that underwent mastectomy were on average younger (58 vs 63 years, p=0.005), had a lower BMI (28 vs 30 kg/m2, p=0.008), were more likely to have higher stage disease (stage 0, I, II rates: 22%, 34%, 44% vs 10%, 68%, 22% respectively, pTable 2. There were no significant differences in location of residency, type of insurance, use of supplemental insurance, prescription drug coverage, use of health savings account, change in employment since diagnosis, education level, chemotherapy, hormonal therapy, clinical trial participation or 30-day reoperation rate except postoperative radiation status. A total of 55 matched pairs of patients that underwent BCT and mastectomy were identified to have complete COST score data. No significant differences were observed in COST scores between the 2 groups (adjusted least squares mean: 26.6 vs 24.7, adjusted difference for BCT vs. mastectomy: 1.91, p=0.481). (Table 3) Additional analyses were performed to enhance the robustness of our statistical model and confirm our results. Separate propensity matching schemes evaluating BCT without reconstruction against mastectomy patients, as well as BCT against mastectomy patients including only individuals with complete PROs, demonstrated that COST scores were not significantly different between the compared groups, in line with our prevailing results. This data is included as supplemental material. (eTable 1, 2, 3, 4)

Table 1Patient Demographic and Cancer Characteristics Before and After Propensity Score Matching

BCT, breast-conserving therapy, NA, not applicable.

Table 2Comparison of Socioeconomic and Treatment Factors in the Propensity Score-Matched Samples

*p Values were calculated using McNemar or Bowker’s symmetry test

BCT, breast-conserving therapy; GED, General Educational Development (including patients with some high school education); NA, not applicable; VA, Veterans Affairs.

Table 3Association between Study Outcomes and Treatment Method in the Propensity Score-Matched Samples

∗Adjusted for postoperative radiation, chemotherapy status, hormonal therapy status and credit score

BCT, breast-conserving therapy; COST, COmprehensive Score for financial Toxicity

 Coping strategiesSelf-reported coping strategies for patients that underwent BCT and mastectomy were analyzed. There were no significant differences identified in spendings for basic needs (p=0.530) or leisure activities (p=0.180) between the two groups. (Table 5) Additionally, patients that underwent BCT experienced no significant differences in use of savings for cancer care (p=0.614), borrowed money to cover cancer-related expenses (p=0.853), number of skipped clinic visits to save on costs (p=0.783), delay of breast reconstruction due to concern about costs (p=0.733), and out of pocket spending (p=0.401) compared to patients that underwent mastectomy. (Table 5) Finally, there were no significant differences in the actual and expected financial costs (p=0.092), as well as the degree of financial burden induced by cancer treatment costs to patients or their family (p=0.384) when comparing the BCT and mastectomy groups. (Table 5)

Table 5Coping Strategy for Patients Who Underwent Mastectomy and Breast-Conserving Therapy

*p Values were calculated using Bowker’s symmetry test

Discussion The rising cost of cancer care has significant implications on patients’ quality of life and oncologic outcomes.2Lentz R. Benson A.B. Kircher S. Financial toxicity in cancer care: Prevalence, causes, consequences, and reduction strategies., 3Gordon L.G. Merollini K.M.D. Lowe A. Chan R.J. A Systematic Review of Financial Toxicity Among Cancer Survivors: We Can’t Pay the Co-Pay., 4Zafar S.Y. Peppercorn J.M. Schrag D. et al.The financial toxicity of cancer treatment: a pilot study assessing out-of-pocket expenses and the insured cancer patient’s experience.,6Zheng Z. Han X. Guy G.P. et al.Do cancer survivors change their prescription drug use for financial reasons? Findings from a nationally representative sample in the United States.,8Kent E.E. Forsythe L.P. Yabroff K.R. et al.Are survivors who report cancer-related financial problems more likely to forgo or delay medical care?., 9Zafar S.Y. McNeil R.B. Thomas C.M. Lathan C.S. Ayanian J.Z. Provenzale D. Population-based assessment of cancer survivors’ financial burden and quality of life: a prospective cohort study., 10Ell K. Xie B. Wells A. et al.Economic stress among low-income women with cancer: effects on quality of life., 11Fenn K.M. Evans S.B. McCorkle R. et al.Impact of financial burden of cancer on survivors’ quality of life., 12Carrera P.M. Kantarjian H.M. Blinder V.S. The financial burden and distress of patients with cancer: Understanding and stepping-up action on the financial toxicity of cancer treatment., 13Ramsey S.D. Bansal A. Fedorenko C.R. et al.Financial Insolvency as a Risk Factor for Early Mortality Among Patients With Cancer. This is especially salient to patients with breast cancer.18Greenup R.A. Rushing C. Fish L. et al.Financial Costs and Burden Related to Decisions for Breast Cancer Surgery., 19Rosenzweig M. West M. Matthews J. et al.Financial Toxicity Among Women With Metastatic Breast Cancer., 20Wheeler S.B. Spencer J.C. Pinheiro L.C. et al.Financial Impact of Breast Cancer in Black Versus White Women.,22Coroneos C.J. Lin Y.-L. Sidey-Gibbons C. et al.Correlation Between Financial Toxicity, Quality of Life, and Patient Satisfaction in an Insured Population of Breast Cancer Surgical Patients: A Single-Institution Retrospective Study. Identifying factors triggering or worsening FT is critical to address this issue. In the present single-institution study, the propensity score-matched technique was used to discern the differential risk of FT attributable to the surgical approach for early-stage breast cancer. We found comparable patient-reported FT in patients undergoing BCT and mastectomy for early-stage breast cancer. Additionally, increasing age, high annual household income and availability of supplemental insurance were also identified as being protective against FT in early-stage breast cancer.Our findings are harmonious with the null hypothesis and the previous Greenup study, which reported that women receiving mastectomy were exposed to greater financial distress compared to those receiving BCT.18Greenup R.A. Rushing C. Fish L. et al.Financial Costs and Burden Related to Decisions for Breast Cancer Surgery. Smith et al. demonstrated that unilateral mastectomy with reconstruction resulted in higher complication rates, as well as complication-specific and overall adjusted costs compared to BCT.29

Smith BD, Jiang J, Shih Y-C, et al. Cost and Complications of Local Therapies for Early-Stage Breast Cancer. J Natl Cancer Inst. 2017;109(1):djw178. Erratum in: J Natl Cancer Inst. 2018;110(10):1148-1152.

However, this study focused on total treatment costs and not patient-reported financial distress. Furthermore, the Greenup and Smith studies indicate that mastectomy may be associated with increased treatment costs and financial burden due to higher rate of complications. On the other hand, BCT involves multiple specialties and treatment modalities (i.e. radiation oncology, medical oncology) and occasionally re-excision may be required to obtain negative margins, with an attendant potential for additional financial burden to the patient. This may potentially explain why these treatment modalities are associated with similar FT. One factor that needs to be taken into consideration when interpreting our results is the fact that breast cancer patients receive an array of treatments, including surgery, radiation, hormonal therapy and/or chemotherapy, which may lead patients to reach their deductibles early in the treatment process. In that case, adding further surgeries or treatments may have little marginal impact on patient out-of-pocket spending, further explaining our findings that FT was similar in both groups. Additionally, our study sample had a preponderance of demographic characteristics known to be protective against financial toxicity e.g. employment status, a majority having an annual household income > $80,000 and being married or in committed relationships.21Offodile A.C. Asaad M. Boukovalas S. et al.Financial Toxicity Following Surgical Treatment for Breast Cancer: A Cross-sectional Pilot Study.,30Huntington S.F. Weiss B.M. Vogl D.T. et al.Financial toxicity in insured patients with multiple myeloma: a cross-sectional pilot study. As a result, the economically advantaged status of our study population may be a mediating factor in the relationships between FT and surgical treatment modalities.38Asaad M. Boukovalas S. Chu C.K. et al.Financial toxicity and contralateral prophylactic mastectomy: an analysis using propensity score methods.Factors associated with higher FT in patients with early breast cancer include low credit score, low annual income, no supplemental insurance and a change in employment status. These findings are in alignment with previous studies, which have shown that low household income, limited or no insurance coverage, changes in work hours or employment status correlate with worsened FT.16Jagsi R. Pottow J.A.E. Griffith K.A. et al.Long-term financial burden of breast cancer: experiences of a diverse cohort of survivors identified through population-based registries., 17Jagsi R. Abrahamse P.H. Lee K.L. et al.Treatment decisions and employment of breast cancer patients: Results of a population-based survey., 18Greenup R.A. Rushing C. Fish L. et al.Financial Costs and Burden Related to Decisions for Breast Cancer Surgery., 19Rosenzweig M. West M. Matthews J. et al.Financial Toxicity Among Women With Metastatic Breast Cancer., 20Wheeler S.B. Spencer J.C. Pinheiro L.C. et al.Financial Impact of Breast Cancer in Black Versus White Women. Racial minorities (blacks and Hispanics), younger age at diagnosis and chemotherapy have been previously associated with increased financial distress, however, these factors were not found to have a significant impact on COST scores in our study.16Jagsi R. Pottow J.A.E. Griffith K.A. et al.Long-term financial burden of breast cancer: experiences of a diverse cohort of survivors identified through population-based registries., 17Jagsi R. Abrahamse P.H. Lee K.L. et al.Treatment decisions and employment of breast cancer patients: Results of a population-based survey., 18Greenup R.A. Rushing C. Fish L. et al.Financial Costs and Burden Related to Decisions for Breast Cancer Surgery., 19Rosenzweig M. West M. Matthews J. et al.Financial Toxicity Among Women With Metastatic Breast Cancer., 20Wheeler S.B. Spencer J.C. Pinheiro L.C. et al.Financial Impact of Breast Cancer in Black Versus White Women. Inclusion of patients with all stages of breast cancer, variability in patient characteristics of study populations and comparison without propensity score matching in those studies may explain the aforementioned discrepancies.It is well-described that oncologic outcomes of early breast cancer treatment are at least equivalent if not favorable for BCT in appropriately selected candidates.15Veronesi U. Cascinelli N. Mariani L. et al.Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer.,23van Maaren M.C. de Munck L. de Bock G.H. et al.10 year survival after breast-conserving surgery plus radiotherapy compared with mastectomy in early breast cancer in the Netherlands: a population-based study., 24Hwang E.S. Lichtensztajn D.Y. Gomez S.L. et al.Survival after lumpectomy and mastectomy for early stage invasive breast cancer: the effect of age and hormone receptor status., 25Mogal H.D. Clark C. Dodson R. et al.Outcomes After Mastectomy and Lumpectomy in Elderly Patients with Early-Stage Breast Cancer., 26Agarwal S. Pappas L. Neumayer L. et al.Effect of breast conservation therapy vs mastectomy on disease-specific survival for early-stage breast cancer., 27Vicini F.A. Cecchini R.S. White J.R. et al.Long-term primary results of accelerated partial breast irradiation after breast-conserving surgery for early-stage breast cancer: a randomised, phase 3, equivalence trial.,39De La Cruz L. Blankenship S.A. Chatterjee A. et al.Outcomes After Oncoplastic Breast-Conserving Surgery in Breast Cancer Patients: A Systematic Literature Review. Decision making between BCT and mastectomy is influenced by multiple factors related to clinicopathologic characteristics (i.e. tumor size, breast size, history of previous radiation), individual patient characteristics (i.e. race, cultural beliefs, socioeconomical status) and physician characteristics (i.e. gender, training, experience, personal preference).40Pukancsik D. Kelemen P. Újhelyi M. et al.Objective decision making between conventional and oncoplastic breast-conserving surgery or mastectomy: An aesthetic and functional prospective cohort study., 41Margenthaler J.A. Ollila D.W. Breast Conservation Therapy Versus Mastectomy: Shared Decision-Making Strategies and Overcoming Decisional Conflicts in Your Patients., 42Gu J. Groot G. Boden C. et al.Review of Factors Influencing Women’s Choice of Mastectomy Versus Breast Conserving Therapy in Early Stage Breast Cancer: A Systematic Review., 43Gu J. Delisle M. Engler-Stringer R. Groot G. Mastectomy versus breast-conservation therapy: an examination of how individual, clinicopathologic, and physician factors influence decision-making., 44Katz S.J. Lantz P.M. Janz N.K. et al.Patient involvement in surgery treatment decisions for breast cancer. Katz et al. demonstrated that over 20% of patients reported that the decision was made by their surgeon with or without their input44Katz S.J. Lantz P.M. Janz N.K. et al.Patient involvement in surgery treatment decisions for breast cancer., and in a different study by Lee et al. less than half of enrolled women were asked about their preference.45Lee C.N. Chang Y. Adimorah N. et al.Decision making about surgery for early-stage breast cancer. These findings highlight the unmet need for shared decision making. Greenup et al showed that in women with annual income less than $45,000, cost was more important than breast appearance when deciding on treatment modality.18Greenup R.A. Rushing C. Fish L. et al.Financial Costs and Burden Related to Decisions for Breast Cancer Surgery. In fact, 28% of women reported that costs associated with their therapies were a key driver of treatment choice.18Greenup R.A. Rushing C. Fish L. et al.Financial Costs and Burden Related to Decisions for Breast Cancer Surgery. However, 78% of women did not discuss costs and associated financial burden with their cancer team and this is consistent with previous literature.18Greenup R.A. Rushing C. Fish L. et al.Financial Costs and Burden Related to Decisions for Breast Cancer Surgery.,40Pukancsik D. Kelemen P. Újhelyi M. et al.Objective decision making between conventional and oncoplastic breast-conserving surgery or mastectomy: An aesthetic and functional prospective cohort study., 41Margenthaler J.A. Ollila D.W. Breast Conservation Therapy Versus Mastectomy: Shared Decision-Making Strategies and Overcoming Decisional Conflicts in Your Patients., 42Gu J. Groot G. Boden C. et al.Review of Factors Influencing Women’s Choice of Mastectomy Versus Breast Conserving Therapy in Early Stage Breast Cancer: A Systematic Review., 43Gu J. Delisle M. Engler-Stringer R. Groot G. Mastectomy versus breast-conservation therapy: an examination of how individual, clinicopathologic, and physician factors influence decision-making., 44Katz S.J. Lantz P.M. Janz N.K. et al.Patient involvement in surgery treatment decisions for breast cancer. Given the proven correlation between FT and quality of life and survival, it is critical to incorporate discussion of pertinent financial information to patient counseling to optimize shared decision-making.Today’s healthcare environment is increasingly characterized by a focus on achieving value for patients, defined as maximizing outcomes per unit cost.46What is value in health care?.,47Sheckter C.C. Matros E. Lee G.K. et al.Applying a value-based care framework to post-mastectomy reconstruction. This proposition is relevant in breast oncology where equally effective treatment decisions, i.e. preferences sensitive, are pervasive e.g. receipt of contralateral prophylactic mastectomy, lumpectomy vs. mastectomy for early stage disease.38Asaad M. Boukovalas S. Chu C.K. et al.Financial toxicity and contralateral prophylactic mastectomy: an analysis using propensity score methods. Therefore, broader deliberations regarding cost, quality of life, and complication profile must inform the patient-centered value calculation.29

Smith BD, Jiang J, Shih Y-C, et al. Cost and Complications of Local Therapies for Early-Stage Breast Cancer. J Natl Cancer Inst. 2017;109(1):djw178. Erratum in: J Natl Cancer Inst. 2018;110(10):1148-1152.

Incorporating FT information portends better alignment with the values, preferences of these patients.28Offodile A.C. Hwang E.S. Greenup R.A. Contralateral Prophylactic Mastectomy in the Era of Financial Toxicity: An Additional Point for Concern?. The American Society of Clinical Oncology (ASCO) has put forth guidelines for providers to identify and address patients’ concerns regarding treatment costs.48Gilligan T. Coyle N. Frankel R.M. et al.Patient-Clinician Communication: American Society of Clinical Oncology Consensus Guideline.FT has been associated with cost-coping strategies, including modifications in spending patterns and decreased compliance with treatment.2Lentz R. Benson A.B. Kircher S. Financial toxicity in cancer care: Prevalence, causes, consequences, and reduction strategies.,21Offodile A.C. Asaad M. Boukovalas S. et al.Financial Toxicity Following Surgical Treatment for Breast Cancer: A Cross-sectional Pilot Study.,49Bouberhan S. Shea M. Kennedy A. et al.Financial toxicity in gynecologic oncology.,50Tucker-Seeley R.D. Yabroff K.R. Minimizing the “financial toxicity” associated with cancer care: advancing the research agenda. The authors have previously demonstrated that breast cancer surgical patients reporting high FT are more likely to decrease spendings on food, clothing and recreational activities, increase spendings to pay for treatment-associated expenses, skip clinic visits, as well as delay plastic surgery consulation and completion of breast reconstruction.21Offodile A.C. Asaad M. Boukovalas S. et al.Financial Toxicity Following Surgical Treatment for Breast Cancer: A Cross-sectional Pilot Study. The findings of the current study indicate that in patients with early-stage breast cancer, choice of treatment approach (BCT vs mastectomy) did not have a significant impact on coping strategies. This is consistent with our conclusion that patient-reported FT was comparable in patients undergoing BCT and mastectomy, and emphasizes that FT should not drive decision making regarding surgical treatment modality in this subset of patients.Our study has several limitations that warrant mention. This is a single-institution cross-sectional study and ou