Costs of routine skin cancer screening in Germany: a claims data analysis

[Melanoma prevention - to screen or not to screen?]

Melanoma is one of the most common cancers worldwide with a high mortality rate. However, the smaller the melanoma is when it is first diagnosed, the better the prognosis. Since skin melanomas can be detected relatively easy with the naked eye, systematic skin cancer screening could theoretically reduce melanoma mortality by diagnosing it as early as possible. Evaluations of skin cancer early detection programs show an increase in the incidence of detection of the skin cancer and especially thins melanomas, but so far, no evidence of a decrease in mortality. Current data on patient-related factors show that fewer men and people with lower socioeconomic status participate in skin cancer screening and knowledge about skin cancer-associated factors is low.Based on the current study situation, it is therefore not possible to recommend or advise against skin cancer screening for the asymptomatic population. Screening is recommended for all people at increased risk: fair skin type according to Fitzpatrick I-II, under immunosuppression, more than 50 melanocytic nevi and history of dysplastic and/or large nevi, family history of melanoma, frequent severe sunburns in childhood. In addition, targeted educational campaigns among risk groups (men, people with low levels of education) are needed.New imaging techniques such as 3D whole-body photography with additional computer-based, AI-assisted risk assessment of digital dermoscopic images, when integrated into clinical decision-making processes (as "augmented intelligence" - AI), clearly have the potential to improve skin cancer screening, particularly in high-risk and melanoma patients. In combination with human expertise, they can potentially offer a more effective and comprehensive approach to detecting and monitoring skin cancer. Randomized controlled studies must show to what extent this promising technique has proven itself in the clinic and is also suitable for other populations.

Impact of Patient's Age and Physician's Professional Background on the Number Needed to Treat in Malignant Melanoma Detection

Background/Objectives: With regard to excision of pigmented lesions for detection of malignant melanoma (MM), the number needed to treat (NNT) describes the number of melanocytic nevi that need to be biopsied/excised to detect one MM. The aim should be a low NNT. Methods: Single-center data analysis, including dermatohistopathological records of all nevi and MM cases during 2004-2013 at the Department of Dermatology, University Hospital Regensburg (UKR), was performed. We calculated the NNT, correlating it with the patient's age and referring physician. The MM to MM in situ ratio was calculated to quantify early detection. As a secondary objective, we stratified into a pre- and post-2008 dataset, coinciding with the introduction of statutory skin cancer screening in Germany. Results: The overall NNT of 118,668 pigmented lesions was 17.2. We found a linear decrease in NNT towards older patients (R2 = 62%; p < 0.001). The impact of skin cancer screening in 2008 was marked by a reduction in biopsies/excisions, a shift in age distribution, and a decrease in the NNT from 20.3 to 14.7. Office-based dermatologists had an NNT of 22.3, UKR-based dermatologists had an NNT of 8.0, and non-dermatologists had an NNT of 16.5. Conclusions: The age-related decrease in the NNT emphasizes the importance of age stratification for pigmented lesions. The NNT differed between professional settings. The implementation of skin cancer screening in 2008 was associated with a reduced NNT.

Skin Cancer Screening and Medical Treatment Intensity in Patients with Malignant Melanoma and Non-Melanocytic Skin Cancer

BACKGROUND

This cohort study concerns the effect of skin cancer screening (SCS) on medical treatment intensity in patients with skin cancer.

METHODS

Routine data from persons aged 35 to 99 who were insured by the AOK health insurance company were used to identify persons who received a diagnosis of malignant melanoma or a non-melanocytic skin cancer in 2014 or 2015, either through skin cancer screening or without screening. These persons were included in cohort studies. The routine data contained no information on tumor stages or grading. Tumor-associated rates of hospital admission, contact with physicians in outpatient practice, and intensity of surgical treatment were determined; rate ratios (RR) and their 95% confidence intervals (CI) were estimated.

RESULTS

The cohort studies included 13 633 patients with melanoma (6480 with SCS and 7153 without) and 118 168 patients with non-melanocytic skin cancer (43 308 with screening and 74 860 without). Patients whose melanomas had been detected by screening had a lower medical treatment intensity than unscreened patients (intensity of tumor-associated surgical treatment (RR = 0.79, 95% CI [0.74; 0.85]), hospital contact rate (RR = 0.44, 95% CI: [0.38; 0.50]), contact with physicians in outpatient practice (RR = 0.79, 95% CI: [0.73; 0.85]). Among patients with non-melanocytic skin cancer, the screened patients displayed a lower hospital contact rate (RR = 0.52, 95% CI: [0.49; 0.56]), a higher contact rate in the outpatient sector (RR = 1.11, 95% CI: [1.08; 1.13]), and no difference in surgical treatment intensity (RR = 0.98, 95% CI: [0.96; 1.00]).

CONCLUSION

SCS is associated with lower medical treatment intensity in the first 12 months after diagnosis in patients with melanoma. Among patients with non-melanocytic skin cancer, those who had been screened had lower hospital contact rates, but there was no observed lowering of other rates reflecting treatment intensity.

One-year follow-up healthcare costs of patients diagnosed with skin cancer in Germany: a claims data analysis

BACKGROUND

Routine skin cancer screening (SCS) is covered by the German statutory health insurance (SHI) since 2008. The objective of this study was to compare direct healthcare costs between patients in whom skin cancer was detected by routine SCS and patients in whom skin cancer was not detected by routine SCS.

METHODS

A retrospective observational study of administrative claims data from a large German SHI was performed. Patients with a diagnosis of malignant melanoma (MM) or non-melanoma skin cancer (NMSC) diagnosed in 2014 or 2015 were included. Costs were obtained for one year before and one year after diagnosis and analyzed in a difference-in-differences approach using regression models. Frequency matching was applied and risk adjustment was performed. Additional analyses were conducted, separately for specific age groups, excluding persons who died during the observation period and without taking costs for screening into consideration.

RESULTS

A total of 131,801 patients were included, of whom 13,633 (10.3%) had a diagnosis of MM and 118,168 (89.7%) had a diagnosis of NMSC. The description of total costs (without risk adjustment) shows lower mean total costs among patients whose skin cancer was detected via routine SCS compared to patients in whom skin cancer was not detected by routine SCS (MM: €5,326 (95% confidence interval (CI) €5,073; €5,579) vs. €9,038 (95% CI €8,629; €9,448); NMSC: €4,660 (95% CI €4,573; €4,745) vs. €5,890 (95% CI €5,813; €5,967)). Results of the regression analysis show cost savings of 18.8% (95% CI -23.1; -8.4) through routine SCS for patients with a diagnosis of MM. These cost savings in MM patients were more pronounced in patients younger than 65 years of age. For patients with a diagnosis of NMSC, the analysis yields a non-substantial increase in costs (2.5% (95% CI -0.1; 5.2)).

CONCLUSION

Cost savings were detected for persons with an MM diagnosed by routine SCS. However, the study could not detect lower costs due to routine SCS in the large fraction of persons with a diagnosis of NMSC. These results offer important insights into the cost structure of the routine SCS and provide opportunities for refinements.

Effects of workplace skin cancer screenings on preventive and risk behaviour

Aim

Skin cancer is the most prevalent cancer in western countries and is associated with a high burden of disease. Skin cancer screenings can help detect cancer at an early stage and thus allow for better treatment. We aimed to analyse the impact of workplace skin cancer screenings on prevention behaviour and potential spillover effects on non-participants.

Subject and methods

Participants of workplace skin cancer screenings completed questionnaires at 0, 3 and 12 months on knowledge about and attitudes toward skin cancer and prevention behaviours. Effects over time were compared using McNemar tests. For additional analyses we performed logistic regression analyses.

Results

Of the 998 participants (44.7% women, mean age 43.3 years), 26.7% had never attended a skin cancer screening. The proportion of participants seeking shade for UV protection and the number of visits to dermatologists and general practitioners increased significantly in the year following workplace screening (p < 0.05). Two thirds (66.4%) recommended skin cancer screenings to others and at least 39.2% of them were sure that this recommendation was followed. Characteristics associated with participants’ recommendation for screening included female gender (odds ratio: 1.62), older age (odds ratio: 1.02), and lower education (odds ratio: 1.40).

Conclusion

Workplace screenings can complement routine skin cancer screenings. They inform participants about the existence and benefits of screenings and may have spillover effects for peers. They can also serve as another source of information on prevention and risk behaviours.