One-Time Melanoma Screening May Be Cost Effective

BOSTON, Jan. 15 -- Universal one-time melanoma screening of adults ages 50 or older by dermatologists would cost about ,000 per quality-adjusted life year gained, which compares favorably with the cost of breast or colon cancer screening.

Another cost-effective model for melanoma screening would be dermatologist screening of melanoma patients' siblings every two years, reported Elena Losina, Ph.D., of Boston University School of Public Health, and colleagues, in the January issue of the Archives of Dermatology.

Reporting in the same issue of the journal, June K. Robinson, M.D., of Northwestern University in Chicago, and colleagues, found that for patients who have already been diagnosed with cutaneous melanoma, an effective surveillance program was self-examination aided by a partner.

The one-time screening would save 1.6 quality-adjusted life years for every 1,000 patients screened and at a cost of ,100 per quality-life adjusted year gained, Dr. Losina said.

Two other strategies-screening every two years or annual screening by dermatologists-had the potential to save more lives, but the cost per quality-adjusted life year gained would be prohibitive--,700 for screening every two years and ,800 for annual screening, Dr. Losina added.

A fourth strategy, screening by non-dermatologists as part of routine medical examinations followed by referral to dermatologists as needed, was "associated with a projected discounted quality-adjusted life expectancy, from age 50 years, of 13.537 [quality-adjusted live years], with life time skin cancer and screening-related costs of per person."

Siblings of melanoma patients are 2.24 times more like to be diagnosed with melanoma than the general population, so a screening strategy directed at that population had the potential for the greatest gains-screening every two years could save an estimated 9.8 quality-adjusted life years at a cost of ,000 per year gained.

The generally accepted threshold for cost-effectiveness of screening programs is ,000 per quality-adjusted of life year gained, thus both the one-time universal screening strategy and the sibling screening strategies examined in this model fit the paradigm.

Dr. Losina and colleagues constructed a mathematical model to test the cost-effectiveness of the competing strategies.

The authors noted that the study was limited by a number of factors including the need to rely on data from multiple sources and the authors' reliance on an assumed constant 10% rate of melanoma progression, which may over-estimate or underestimate the true progression rate.

The model also failed to account for detection of non-melanoma skin cancer which is approximately 20 times more common than melanoma and shares many of the same risk factors. "Non-melanoma skin cancer may be diagnosed in a melanoma screening program, adding both costs and benefits."

In the Chicago melanoma screening study, Dr. Robinson and colleagues recruited 130 patients who had been diagnosed with cutaneous melanoma. The patients were evenly assigned to solo training in skin self examination or dyadic learning.

After four months, the paired-learning individuals were significantly more likely to report regular skin self-examination of the face (P<0.001) and the skin in general (P<0.001) than the solo-learning individuals.

Only 23 of the paired-learning individuals said they had not performed regular skin checks versus 45 of the solo-learners (P<0.05), Dr. Robinson said.

"Attitude and belief in the ability to perform skin self-examination are fostered when the partners learn about melanoma recognition and skills training together," Dr. Robinson said.

Moreover, she said that partner-learning offers the practical advantage of having someone who can check "locations that are difficult for the patient to see, for example the scalp, back, ears and back of legs."

All cancer screening programs are fraught with difficulty, said Howard K. Koh, M.D., M.P.H., of the Harvard School of Public Health in Boston, in an accompanying editorial.

Melanoma screening, for example, seems easy but it is not, "In this area, an ounce of prevention is a ton of work," Dr. Koh wrote.

Unlike breast or colon cancer, for melanoma "no randomized prospective clinical screening trial exists worldwide," Dr. Koh noted.

But Dr. Koh said the mathematical model by Dr. Losina and colleagues added welcome "focus and another layer of sophistication" to the melanoma screening debate.

He concluded the Losina "analysis not only reinforces consideration of one-time screening for melanoma but also resurrects hopes for a definitive randomized trial using this strategy."