Stage-specific direct health care costs in patients with cutaneous malignant melanoma

Cost items in melanoma patients by clinical characteristics and time from diagnosis

Background

Costs related to the care of melanoma patients have been rising over the past few years due to increased disease incidence as well as the introduction of innovative treatments. The aim of this study is to analyse CMM cost items based on stage at diagnosis, together with other diagnostic and prognostic characteristics of the melanoma.

Methods

Analyses were performed on 2,647 incident cases of invasive CMM that were registered in 2015 and 2017 in the Veneto Cancer Registry (RTV). Direct melanoma-related costs per patient were calculated for each year ranging from 2 years before diagnosis to 4 years after, and were stratified by cost items such as outpatient services, inpatient drug prescriptions, hospital admissions, hospice admissions, and emergency room treatment. Average yearly costs per patient were compared according to available clinical-pathological characteristics. Lastly, log-linear multivariable analysis was performed to investigate potential cost drivers among these clinical-pathological characteristics.

Findings

Overall, the average direct costs related to melanoma are highest in the first year after diagnosis (€2,903) and then decrease over time. Hospitalization costs are 8 to 16 times higher in the first year than in subsequent years, while the costs of outpatient services and inpatient drugs decrease gradually over time. When stratified by stage it is observed that the higher expenditure associated with more advanced stages of CMM is mainly due to inpatient drug use.

Conclusion

The results of the present study show that grouping patients according to tumour characteristics can improve our understanding of the different cost items associated with cutaneous malignant melanoma. CMM patients experience higher costs in the first year after diagnosis due to higher hospitalization and outpatient services. Policy makers should consider overall and stage-specific annual costs when allocating resources for the management of CMM patients.

Melanoma literacy among the general population of three western US states

Melanoma is a significant cause of cancer death, despite being detectable without specialized or invasive technologies. Understanding barriers to preventive behaviors such as skin self-examination (SSE) could help to define interventions for increasing the frequency of early detection. To determine melanoma knowledge and beliefs across three high-incidence US states, 15,000 surveys were sent to a population-representative sample. We aimed to assess (1) melanoma literacy (i.e., knowledge about melanoma risks, attitudes, and preventive behaviors) and (2) self-reported SSE and its association with melanoma literacy, self-efficacy, and belief in the benefits of SSE. Of 2326 respondents, only 21.2% provided responses indicating high knowledge of melanoma, and 62.8% reported performing an SSE at any time in their lives. Only 38.3% and 7.3% reported being "fairly" or "very" confident about doing SSE, respectively. SSE performance among respondents was most strongly associated with higher melanoma knowledge, higher self-efficacy, and personal history of melanoma. Melanoma literacy among survey respondents was modest, with greater literacy associated with a higher likelihood of reported preventive behavior. This assessment establishes a baseline and provides guidance for public health campaigns designed to increase prevention and early detection of this lethal cancer.

Prioritizing Melanoma Surgeries to Prevent Wait Time Delays and Upstaging of Melanoma during the COVID-19 Pandemic

Prompt diagnosis and surgical management of melanoma strongly impact prognosis. Considering the limited resources, emergency closures, and staffing shortages during the COVID-19 pandemic in Canada, our institution implemented a dedicated care pathway to prioritize cancer surgeries. We aim to assess whether this strategy was effective at preventing surgical wait time delays and upstaging of melanoma. We retrospectively collected data of patients aged ≥18 years with biopsy-proven primary melanoma who underwent wide local excision (WLE) ± sentinel lymph node biopsy (SLNB) between 1 March 2018-29 February 2020 (pre-pandemic) and 1 March 2020-22 March 2022 (pandemic). Patients with distant metastasis, recurrence, in situ disease, and unknown primary were excluded. Wait time from consult to surgery, tumour (T) and nodal (N) stage, and overall stage were collected. Results: We included 419 patients [pre-pandemic (n = 204) and pandemic (n = 215)]. Median wait time (days) [interquartile range] to surgery was 36 [22-48] pre-pandemic and 35 [24-49] during the pandemic (p = 0.888). There were no differences found in T stage (p = 0.060), N stage (p = 0.214), or overall melanoma stage (p = 0.192). We highlight the importance of streamlining melanoma surgery during a pandemic. As the need arises to meet surgical backlogs including benign surgery, dedicated cancer surgery should maintain a priority to not negatively affect cancer outcomes.

Melanoma-related costs by disease stage and phase of management in Ireland

BACKGROUND

Management options for the treatment of melanoma have expanded in recent years. In an era of promising, but expensive novel pharmacological treatments, robust stage-specific melanoma-related cost estimates are necessary to support budgetary planning, evaluation of cost-effectiveness and to contribute to the investment case for prevention.

METHODS

A detailed decision model, describing the melanoma care pathway (by disease stage) from diagnosis, through treatment and follow-up was developed over a 5-year time frame from the perspective of the Irish healthcare system. The model was populated with real-world data from the National Cancer Registry Ireland. Uncertainty was explored using one-way and probabilistic sensitivity analysis.

RESULTS

The cost of managing a case of melanoma diagnosed at Stage IV (€122 985) was more than 25 times more expensive than managing a case diagnosed at Stage IA (€4269). Total costs were sensitive to the choice of immunotherapeutic and targeted drug, duration of treatment and proportion of patients receiving immunotherapy agents.

CONCLUSIONS

The rising incidence of melanoma and high cost of new novel therapies presents an immediate challenge to cancer control and public health globally. This study highlights the cost differential between early and late detection and the potential return on investment for prevention versus high-cost treatment.

Spending and Hospital Stay for Melanoma in Hunan, China

Objective

This study aimed to describe the economic burden of Chinese patients with melanoma in Hunan province of China, and to investigate the factors for hospitalization spending and length of stay (LOS) in patients undergoing melanoma surgery.

Methods

Data was extracted from the Chinese National Health Statistics Network Reporting System database in Hunan province during 2017–2019. Population and individual statistics were presented, and nonparametric tests and quantile regression were used to analyze the factors for spending and LOS.

Result

A total of 2,644 hospitalized patients with melanoma in Hunan were identified. During 2017–2019, the total hospitalization spending was $5,247,972, and out-of-pocket payment (OOP) was $1,817,869, accounting for 34.6% of the total expenditure. The median spending was $1,123 [interquartile range (IQR): $555–2,411] per capita, and the median LOS was 10 days (IQR: 5–18). A total of 1,104 patients who underwent surgery were further analyzed. The non-parametric tests and quantile regression showed that women were associated with less spending and LOS than men. In general, patients aged 46–65 and those with lesions on the limbs had higher hospitalization costs and LOS than other subgroups.

Conclusion

Melanoma causes heavy economic burdens on patients in Hunan, such that the median spending is close to 60% of the averagely annual disposable income. Middle-aged men patients with melanoma on the limbs present the highest financial burden of melanoma.

Sex Differences in Cutaneous Melanoma: Incidence, Clinicopathological Profile, Survival, and Costs

Background: This study aims to provide a comprehensive overview of sex-related characteristics of cutaneous malignant melanoma (CMM), with special reference to its incidence, clinicopathological profile, overall survival, and treatment-related costs. Methods: This retrospective cohort study included all 1,279 CMM patients who were registered in 2015 in the Veneto Cancer Registry (a population-based registry including all 4,900,000 regional residents). The by-sex comparisons included tumor stage and site, histological subtype, and other clinical-pathological variables. A Cox regression analysis was used to test the association between sex and survival, adjusting for the main covariates. Treatment costs were calculated by linking patients with several administrative regional databases. Results: Age-specific incidence rates were significantly higher for men among people >50 years old. For men, the trunk was the most common primary site (59.3%), whereas for women the lower limbs (32.1%) were the most common primary site, followed by the trunk (31.8%), which was lower than for men (p < 0.001). At presentation, the frequency of early stage CMM was higher among women, who also featured a significantly lower risk of death (p = 0.016), after adjusting for covariates. Men also incurred higher costs for melanoma treatment in the first year after their diagnosis. Conclusions: Among younger adults, CMM was more common in women, whereas among older adults, it was more common in men. Sex also influences patients' histopathological characteristics at diagnosis. Women had better overall survival after adjusting for demographic, pathological, and clinical profiles. The costs of treatment were also lower for women with CMM.

Efficiency of Detecting New Primary Melanoma Among Individuals Treated in a High-risk Clinic for Skin Surveillance

Importance

A previous single-center study observed fewer excisions, lower health care costs, thinner melanomas, and better quality of life when surveillance of high-risk patients was conducted in a melanoma dermatology clinic with a structured surveillance protocol involving full-body examinations every 6 months aided by total-body photography (TBP) and sequential digital dermoscopy imaging (SDDI).

Objective

To examine longer-term sustainability and expansion of the surveillance program to numerous practices, including a primary care skin cancer clinic setting.

Design, Setting, and Participants

This prospective cohort study recruited 593 participants assessed from 2012 to 2018 as having very high risk of melanoma, with a median of 2.9 years of follow-up (interquartile range, 1.9-3.3 years), from 4 melanoma high-risk clinics (3 dermatology clinics and 1 primary care skin cancer clinic) in New South Wales, Australia. Data analyses were conducted from February to September 2020.

Exposures

Six-month full-body examination with the aid of TBP and SDDI. For equivocal lesions, the clinician performed SDDI at 3 or 6 months.

Main Outcomes and Measures

All suspect monitored or excised lesions were recorded, and pathology reports obtained. Outcomes included the incidence and characteristics of new lesions and the association of diagnostic aids with rates of new melanoma detection.

Results

Among 593 participants, 340 (57.3%) were men, and the median age at baseline was 58 years (interquartile range, 47-66 years). There were 1513 lesions excised during follow-up, including 171 primary melanomas. The overall benign to malignant excision ratio, including keratinocyte carcinomas, was 0.8:1.0; the benign melanocytic to melanoma excision ratio was 2.4:1.0; and the melanoma in situ to invasive melanoma ratio was 2.2:1.0. The excision ratios were similar across the 4 centers. The risk of developing a new melanoma was 9.0% annually in the first 2 years and increased with time, particularly for those with multiple primary melanomas. The thicker melanomas (>1-mm Breslow thickness; 7 of 171 melanomas [4.1%]) were mostly desmoplastic or nodular (4 of 7), self-detected (2 of 7), or clinician detected without the aid of TBP (3 of 7). Overall, new melanomas were most likely to be detected by a clinician with the aid of TBP (54 of 171 [31.6%]) followed by digital dermoscopy monitoring (50 of 171 [29.2%]).

Conclusions and Relevance

The structured surveillance program for high-risk patients may be implemented at a larger scale given the present cohort study findings suggesting the sustainability and replication of results in numerous settings, including a primary care skin cancer clinic.

Trend Shifts in Age-Specific Incidence for In Situ and Invasive Cutaneous Melanoma in Sweden

BACKGROUND

The incidence of invasive cutaneous melanoma (CM) is increasing in Sweden. The aim was to present age- and sex-specific trends of the age-standardised incidence and the average annual percentage change (AAPC) for in situ and invasive CM.

METHODS

Joinpoint regression models were used to analyse data from the Swedish Cancer Register and the Swedish Melanoma Registry 1997-2018 (N = 35,350 in situ CM; 59,932 CM).

RESULTS

The AAPC of CM for women was 4.5 (4.1-5.0; p < 0.001) for the period 1997-2018. For men, the APCC was 4.2 (3.0-5.4; p < 0.001), with a significantly higher annual percentage change (APC) for the period 2000-2018 (5.0; 4.6-5.4; p < 0.001) compared to 1997-1999. An increasing annual incidence of CM ≤ 0.6 mm and 0.7 mm Breslow tumour thickness was found for men with a significant incidence shift for the period 2006-2015, respectively. Similarly for women, with a significantly higher APC for CM ≤ 0.6 mm from 2005. The incidence of intermediate thick CM (2.1-4.0 mm) has not increased since 2011. The incidence of CM > 4.0 mm has been increasing among both sexes, with a significantly lower APC among women from 2005.

CONCLUSIONS

The incidence of in situ and low-risk CM ≤ 1.0 mm in tumour thickness has been rising among both sexes since the 2000s.

Association of Indoor Tanning Regulations With Health and Economic Outcomes in North America and Europe

Importance

UV radiation emissions from indoor tanning devices are carcinogenic. Regulatory actions may be associated with reduced exposure of UV radiation at a population level.

Objective

To estimate the long-term health and economic consequences of banning indoor tanning devices or prohibiting their use by minors only in North America and Europe compared with ongoing current levels of use.

Design, Setting, and Participants

This economic analysis modeled data for individuals 12 to 35 years old in North America and Europe, who commonly engage in indoor tanning. A Markov cohort model was used with outcomes projected during the cohort's remaining life-years. Models were populated by extracting data from high-quality systematic reviews and meta-analyses, epidemiologic reports, and cancer registrations.

Main Outcomes and Measures

Main outcomes were numbers of melanomas and deaths from melanoma, numbers of keratinocyte carcinomas, life-years, and health care and productivity costs. Extensive sensitivity analyses were performed to assess the stability of results.

Results

In an estimated population of 110 932 523 in the United States and Canada and 141 970 492 in Europe, for the next generation of youths and young adults during their remaining lifespans, regulatory actions that ban indoor tanning devices could be expected to gain 423 000 life-years, avert 240 000 melanomas (-8.2%), and avert 7.3 million keratinocyte carcinomas (-7.8%) in North America and gain 460 000 life-years, avert 204 000 melanomas (-4.9%), and avert 2.4 million keratinocyte carcinomas (-4.4%) in Europe compared with ongoing current levels of use. Economic cost savings of US $31.1 billion in North America and €21.1 billion (US $15.9 billion) in Europe could occur. Skin cancers averted and cost savings after prohibiting indoor tanning by minors may be associated with one-third of the corresponding benefits of a total ban.

Conclusions and Relevance

Banning indoor tanning may be associated with reduced skin cancer burden and health care costs. Corresponding gains from prohibiting indoor tanning by minors only may be smaller.

Prevalence of skin examination behaviours among Australians over time

BACKGROUND

We aimed to examine the prevalence and correlates of opportunistic skin check behaviours among Australians and whether changes over time might explain increasing underlying rates of melanoma in situ.

METHODS

The National Sun Protection Survey involved periodic telephone-based cross-sectional surveys during summer since 2003. Skin checks by a doctor in the past 12 months was asked in four summers over 2006-2017, and responses from 23,374 Australians aged 12-69 years were analysed. Prevalence estimates were weighted to be representative of the Australian population. Chi-square tests compared the prevalence over time and by characteristics.

RESULTS

The overall proportion reporting whole-body skin checks in the past 12 months was 20 % in 2006-07 and 2010-11, 21 % in 2013-14, and 22 % in 2016-17; but increased from 29 % in 2006-07 to 37 % in 2016-17 for those aged 45-69 years (p < 0.0001). In 2016-17, 5% reported a skin check of part-body and 9% for a specific mole or spot. The proportion reporting no skin checks increased from 61 % to 64 % over time (p < 0.0001). Whole-body skin checks were more common among older respondents, females, and also varied by residence location, skin sensitivity, skin colour, risk perception, and socio-economic index (all p < 0.001).

CONCLUSION

Approximately one third of Australians had their skin checked by a doctor within a 12-month period, but this varied across population sub-groups. Skin check behaviours were relatively stable over time, with modest increases in the prevalence of skin checks for those aged 45-69 years. These findings do not explain underlying large increases in rates of melanoma in situ.

Differences in direct costs of patients with stage I cutaneous melanoma: A real-world data analysis

BACKGROUND

Clinical factors, such as tumor thickness, ulceration and growth phase have a role as prognostic factors for stage I melanoma. However, it is still under debate whether these variables influence the related direct costs. We aimed to investigate which clinical factors represent direct health care "cost drivers" for stage I melanoma.

MATERIALS AND METHOD

Analyses were conducted on a cohort of patients diagnosed with stage I melanoma. Differences in the costs incurred by different groups of patients were examined using Mann-Whitney or Kruskal-Wallis non-parametric tests. Log linear multivariate analysis was used to identify the clinical drivers of the total direct costs one and two years after diagnosis. The study was conducted from the perspective of Italy's National Health care System.

RESULTS

One year after diagnosis, patients whose melanomas had a Breslow thickness ≥0.8 mmin (compared with those with lower thickness) and a vertical growth phase (compared with those with radial growth) incurred higher costs for hospitalization, as well as higher overall costs. One year after their diagnosis, treatment of patients with stage I melanoma in the vertical growth phase costs 50% more (95% CI: 22-85%) than their counterparts with a radial growth pattern, resulting in an estimated absolute increase of € 256.23. Having a tumor thicker than 0.8 mm prompted an increase of 91% (95% CI: 43-155%) in the costs (€955.24 in absolute terms).

CONCLUSION

Our data indicate a heterogeneity in the direct costs of stage I melanoma patients during the first year after diagnosis, which can be partly explained by clinical prognostic factors, like tumor thickness and growth pattern.

Mutational Profile of Driver Genes in Brazilian Melanomas

PURPOSE

Mutation testing of the key genes involved in melanoma oncogenesis is now mandatory for the application of targeted therapeutics. However, knowledge of the mutational profile of melanoma remains largely unknown in Brazil.

PATIENTS AND METHODS

In this study, we assessed the mutation status of melanoma driver genes BRAF, NRAS, TERT, KIT, and PDGFRA in a cohort of 459 patients attended at Barretos Cancer Hospital between 2001 and 2012. We used polymerase chain reaction followed by Sanger sequencing to analyze the hot spot mutations of BRAF exon 15 (V600E), NRAS (codons 12/13 and 61), TERT (promoter region), KIT (exons 9, 11, 13, and 17), and PDGFRA (exons 12, 14, and 18) in tumors. The mutational profile was investigated for associations with demographic, histopathologic, and clinical features of the disease.

RESULTS

The nodular subtype was most frequent (38.9%) followed by the superficial spreading subtype (34.4%). The most frequent tumor location was in the limbs (50.0%). The mutation rates were 34.3% for TERT and 34.1% for BRAF followed by NRAS (7.9%), KIT (6.2%), and PDGFRA (2.9%). The BRAF (P = .014) and TERT (P = .006) mutations were associated with younger patients and with different anatomic locations, particularly in the trunk, for the superficial spreading and nodular subtypes, respectively (P = .0001 for both). PDGFRA mutations were associated with black skin color (P = .023) and TERT promoter mutations with an absence of ulceration (P = .037) and lower levels of lactate dehydrogenase. There was no association between patient survival rates and mutational status.

CONCLUSION

The similar mutational profile we observe in melanomas in Brazil compared with other populations will help to guide precision medicine in this country.

Cost-of-illness of melanoma in Europe - a modelling approach

BACKGROUND

Malignant melanoma is accounting for the vast majority of skin cancer death. The treatment and productivity loss due to morbidity or premature mortality are associated with costs for society. There are few cost-of-illness (COI) studies on malignant melanoma in European countries from societal perspective and currently there is no publication analysing the COI in all European countries.

OBJECTIVES

The objective of the present study was to comparatively estimate COI of malignant melanoma in the European countries based on an identical approach.

METHODS

Cost information was obtained from results of a systematic literature research. For countries with no available cost information, a model for imputation of cost data was developed. Country-specific costs were modelled on the national gross domestic product, health expenditures, gross national income and epidemiological data. The adjustment for purchasing power parity allowed a comparison across countries.

RESULTS

Crude national costs of malignant melanoma ranged between € 1.1 million in Iceland and € 543.8 million in Germany and resulted in € 2.7 billion for all EU/EFTA states. Estimated crude costs per patient were lowest in Bulgaria (€ 6422) and highest in Luxembourg (€ 50 734). The share of direct costs varied from 3% to 26% across countries. After adjustment for the purchasing power parity costs per patient ranged between € 14 420 in Bulgaria and € 50 961 in Cyprus. Treatment expenses and morbidity costs were markedly lower for countries that entered the EU since 2004. By contrast, mortality costs were lower in countries with a high gross domestic product per capita.

CONCLUSION

In this first estimation, malignant melanoma induces relevant COI in Europe. There was large variation in the costs per patient due to different health care systems and expenses. Beyond decreasing patient burden, early intervention and prevention of melanoma could have a relevant potential to save costs across Europe.

Cost-of-illness of melanoma in Europe - a systematic review of the published literature

Malignant melanoma accounts for the vast majority of skin cancer deaths. Primary prevention is used to increase knowledge about skin cancer and set incentives for a change in behaviour, which leads to a decrease in cases. Primary prevention may be cost-effective or even cost saving. Cost-of-illness (COI) studies provide information on such potential savings. The purpose of this study is to give an overview on COI studies in European countries and to compare the COI in total and by cost categories. The results can be used to model potential cost savings from prevention. We conducted a systematic literature research in PubMed using the PRISMA checklist. All costs were converted into Euro and adjusted for the reference year 2012. For the ranking of countries according to their COI, all costs were adjusted for the purchasing power parity. All studies focusing on stage III-IV melanoma include information on hospital, hospice, and outpatient treatment. Costs for the treatment of advanced melanoma range between € 2972 in Italy and € 17 408 in Sweden after adjusting for purchasing power parity. Most studies on stage I-IV melanoma include costs of hospitalization, outpatient treatment and general practitioner consultation. Direct costs range from € 923 in Sweden to € 9829 in Denmark. Three articles also include information on indirect costs. Mortality costs vary between € 3511 in Sweden and € 20 408 in England, morbidity costs between € 103 in Sweden and € 4550 in England. We showed that costs for the treatment of skin cancer are moderately high in the included countries. Since after publication of the articles new costly drugs were approved in Europe, treatment costs of melanoma in Europe may be expected to have risen in the last few years, which means that there is a high expectable potential for prevention programmes to become cost-effective or even cost saving.