Specialized Surveillance Cost-Effective, Not Linked to Overtreatment in High-Risk Melanoma Population

A specialized surveillance program designed to monitor individuals deemed at high risk for melanoma proved cost-effective and may reduce overtreatment rates compared with standard care, according to study results published in Journal of Clinical Oncology


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Australian clinical guidelines suggest that individuals at high risk for developing melanoma regularly undergo surveillance to promote early detection. The Sydney Melanoma Diagnostic Centre at Royal Prince Alfred Hospital opened a High Risk Clinic in 2006, and results have suggested its efficacy in detecting melanoma. However, questions remain about the cost-effectiveness of specialized surveillance, as well its ability to reduce the number of invasive procedures performed.

Caroline G Watts, MPH, of the Sydney School of Public Health at University of Sydney (New South Wales, Australia), and colleagues sought to determine the costs and benefits of specialized monitoring vs standard community care over a 10-year period through the use of a decision-analytic model. The researchers identified 311 high-risk patients who underwent specialized surveillance at the High Risk Clinic over a 5-year period, as well as 607 high-risk patients identified from the Sax Institute’s 45 and Up cohort study, who received standard care in the community medical setting.

Specialized care consisted of twice-yearly clinic visits. Patients with suspicious lesions either underwent excision or additional review after 3 months. The researchers assumed that patients undergoing standard care received an annual skin examination from their primary physician or dermatologist.

Ms Watts and colleagues found that individuals receiving specialized surveillance had a mean savings of $6828 (95% CI, 5564-9029) per patient and a mean gain in quality-of-life years of 0.31 (95% CI, 0.27-0.35) compared with standard care patients. Specialized surveillance was further associated with a lower mean cost per patient over a 10-year period (mean, $13468 vs $20296).

The researchers identified the detection of melanoma at earlier disease stages as the main driver of difference between specialized surveillance and standard care. Patients receiving specialized surveillance had a lower annual probability of excision (0.4; 95% CI, 0.33-0.46), which corresponded with a smaller annual mean number of suspicious lesions excised (specialized surveillance vs standard care, 0.81 vs 2.55).

Sensitivity analyses showed that variables likely to influence the incremental cost-effectiveness ratio included the probability of excision in both cohorts, as well as the annual cost of specialized surveillance and the costs associated with managing metastatic melanoma. Only the low probability of excision in the standard care cohort was shown to increase the cost-effectiveness ratio above a willingness-to-pay threshold of $50,000 per quality-of-life year.

Watts and colleagues acknowledged study limitations, including the lack of data on hospitalization costs for patients with keratinocytic lesions. Further, due to the study’s retrospective design, the researchers could not control for differences in family risk history and other high-risk characteristics between groups.

“Further exploration of risk factors may help to identify patients who require less intensive surveillance, because not all patients had a lesion excised over the study period,” wrote Ms Watts and colleagues. “For some cancers, a less-intensive follow-up program has been shown to be the most cost-effective approach. However, our findings indicate that for high-risk patients managed with specialized surveillance, rather than contributing to overtreatment, surveillance with a careful watch-and-wait approach to suspicious skin lesions resulted in fewer excisions and lower costs overall compared with surveillance in the community.”