Economic Costs Avoided by Diagnosing Melanoma Six Months Earlier Justify >100 Benign Biopsies
May 2016 | Volume 15 | Issue 5 | Original Article | 527 | Copyright © May 2016
Daniel J. Aires MD JD,*a Jo Wick PhD,*b Tarek S. Shaath MD,*c Anand N. Rajpara MD,a Vikas Patel MD,a Ahmed H. Badawi PhD,c Cicy Li MS,c Garth R. Fraga MD,d Gary Doolittle MD,e and Deede Y. Liu MDa
*Indicates that these authors contributed equally.
aDivision of Dermatology, University of Kansas Medical Center, Kansas City, KS
bDepartment of Biostatistics, University of Kansas Medical Center, Kansas City, KS
cUniversity of Kansas School of Medicine, Kansas City, KS
dDepartment of Pathology and Laboratory Medicine, University of Kansas Medical Center, Kansas City, KS
eDivision of Medical Oncology, University of Kansas Medical Center, Kansas City, KS
New melanoma drugs bring enormous benefits but do so at significant costs. Because melanoma grows deeper and deadlier over time, deeper lesions are costlier due to increased sentinel lymph node biopsy, chemotherapy, and disease-associated income loss. Prior studies have justified pigmented lesion biopsies on a “value per life” basis; by contrast we sought to assess how many biopsies are justified per melanoma found on a purely economic basis. We modeled how melanomas in the United States would behave if diagnosis were delayed by 6 months, eg, not biopsied, only observed until the next surveillance visit. Economic loss from delayed biopsy is the obverse of economic benefit of performing biopsy earlier. Growth rates were based on Liu et al. The results of this study can be applied to all patients presenting to dermatologists with pigmented skin lesions suspicious for melanoma. In-situ melanomas were excluded because no studies to date have modeled growth rates analogous to those for invasive melanoma. We assume conservatively that all melanomas not biopsied initially will be biopsied and treated 6 months later. Major modeled costs are (1) increased sentinel lymph node biopsy, (2) increased chemotherapy for metastatic lesions using increased 5-yr death as metastasis marker, and (3) income loss per melanoma death at $413,370 as previously published. Costs avoided by diagnosing melanoma earlier justify 170 biopsies per melanoma found. Efforts to penalize “unnecessary” biopsies may be economically counterproductive. J Drugs Dermatol.
Cutaneous melanoma is the fifth most common type of cancer in the United States (SEER 2014). One in 50 Americans will be diagnosed with melanoma at some point (SEER). The incidence of melanoma has risen by 1.8% annually over the last three decades. Melanoma incidence in the United States was estimated to reach 76,100 (43,890 men and 32,210 women) in 2014, with a projected 9,710 (6,470 men and 3,240 women) deaths. Newer drugs can extend survival in late stage disease, but carry significant prices. As melanoma incidence and treatment costs rise, economic implications become more salient.
Survival benefits of diagnosing melanoma earlier are clearly documented.1,2 However, the economic advantages to avoiding diagnosis delay have not been studied to a similar extent. There is significant controversy around the timing and method of pigmented lesion biopsies, and around what type of the melanoma screening is justified. Of equal relevance, cost-based healthcare reforms are increasing scrutiny of biopsy rates. Therefore economic analyses of melanoma biopsy costs and their implications may be timely.
Melanoma is a deadly disease primarily because the prognosis for metastatic disease is abysmal, and metastatic risk increases with depth (Table 1). Dermatologists group melanomas into thin, intermediate, and thick lesions. Generally, thin melanomas are those with depth under 1 mm, or sometimes under 0.75 mm. Intermediate thickness melanomas are 1 to 4 mm, or sometimes 0.75-4 mm. Thick melanomas are deeper than 4 mm. Because odds of metastatic spread increase with progressing depth, it is best to catch melanoma early. Some would say this is the first commandment of dermatology.
When examining a given pigmented lesion, the dermatologist often faces a choice of whether or not to biopsy. Dermatologists must balance the risks of delaying a melanoma biopsy versus the risks of performing an unnecessary biopsy. This “benefit-risk assessment,” from a treatment point of view, involves exploring how many biopsies are justified in order to catch a single melanoma. For simplicity, we assume high-risk patients are followed at six-month intervals. If so, the dermatologist must identify the risks of delaying a melanoma biopsy by