March 5, 2007

One-Tme Melanoma Screening Of Older Adults Appears To Be Cost-Effective

One-time melanoma screening of adults age 50 or older appears to be as cost-effective as other nationally recommended cancer screening programs, according to an article in the January issue of Archives of Dermatology, one of the JAMA/Archives journals.

Melanoma is the only cancer for which incidence and death rates continue to increase in the United States, while screening continues to be underused, according to background information in the article. Treating melanoma costs more than $740 million each year in the United States. Older patients and those who have immediate relatives with melanoma are at higher risk. Knowledge regarding risk factors and the availability of treatment has spurred greater interest in screening; however, the lack of a large randomized trial proving screening efficacy has been cited as an obstacle preventing its widespread implementation.

Elena Losina, Ph.D., Boston University School of Public Health, and colleagues constructed a mathematical model to simulate the melanoma events that occur in a population, including disease occurrence, progression, detection with and without a screening program, treatment and death. The authors projected the additional costs of screening and the additional survival attributable to earlier detection. They then assessed the cost in dollars for every extra year of life gained (the cost-effectiveness) from melanoma screening by a dermatologist.

"We considered the following four screening strategies: background screening only; that is, skin examination at a routine non-dermatologist physician visit, followed by referral to a dermatologist, on average, once every five years; and one-time, every two years and annual screening by a dermatologist, all beginning at age 50 years," the authors write.

In the model analysis, the cost-effectiveness of screening was about $10,100 per quality-adjusted life year gained for one-time screening compared with current practice. In other words, for every $10,100 in costs associated with one-time screening, one individual would have one additional year of life because of the screening. In addition, costs totaled $80,700 per quality-adjusted life year gained for screening every two years compared with one-time screening, and $586,800 per quality-adjusted life year gained for annual screening compared with screening every two years. Among siblings of patients with melanoma, one-time screening cost $4,000 per quality-adjusted life year gained compared with current practice, screening every two years cost an additional $35,500 per quality-adjusted life year gained, and annual screening cost an additional $257,800 per quality-adjusted life year gained.

Cost-effectiveness analyses are typically used when large randomized trials of screening procedures cannot be done for either logistical or ethical reasons, the authors write. "Using this method, interventions in the United States are generally considered cost-effective at less than $50,000 per quality-adjusted life year gained or less than $100,000 per quality-adjusted life year gained," they continue.

"This study suggests that one-time screening of the general U.S. population at age 50 years for malignant melanoma is very cost-effective and that screening every two years of siblings of patients with melanoma may also be cost-effective, depending on disease progression rates," according to the authors. "Either screening programs should be expanded or efforts to perform a definitive efficacy trial should be initiated."


(Arch Dermatol. 2007;143:21-28.)

This study was supported by a grant from the National Cancer Institute and grants from the National Institute of Allergy and Infectious Diseases. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

Editorial: Study Provides Valuable Information for Difficult Screening Decision

Although screening strategies are necessary to save lives that would otherwise be lost to cancer, controversies abound when decisions about screening recommendations are discussed, writes Howard K. Koh, M.D., M.P.H., Harvard School of Public Health, Boston, in an accompanying editorial.

Such recommendations are ideally based on large, randomized clinical trials of screening methods. "For melanoma, however, no randomized prospective clinical screening trial exists worldwide. Furthermore, none appears to be forthcoming," Dr. Koh writes. "In this context, the new mathematical simulation model published by Losina et al in this issue of the Archives adds focus and another layer of sophistication."

"The cost-effectiveness ratios generated were comparable to those seen for other types of cancer screening, such as for breast cancer and colorectal cancer," he concludes. "This new quantitative analysis not only reinforces consideration of one-time screening for melanoma but also resurrects hopes for a definitive randomized trial using this strategy."

(Arch Dermatol. 2007;143:101-103.)

Please see the article for additional information, including author contributions and affiliations, financial disclosures, funding and support, etc.

Contact: Lisa Brown
JAMA and Archives Journals

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