SCREENING FOR MELANOMA IN MEN: A COST-EFFECTIVENESS ANALYSIS

Purpose: Approximately 10,000 Americans die from melanoma each year; a disproportionate number are white men. Systematic screening skin examination by dermatologists has been proposed to reduce melanoma-related mortality, but its effectiveness is unknown. We developed a Markov model to examine the cost-effectiveness of systematic screening compared with usual care (no systematic screening).

Methods: Using SEER Medicare data for melanoma incidence and previously published cost estimates, we developed a cohort Markov state-transition model to evaluate several screening strategies applied to a hypothetical population of 10,000 white men, compared with no screening. We calibrated model transition probabilities to match: 1) age-adjusted melanoma mortality rate from SEER Medicare data (Caucasian men: 4.6 deaths per 100,000 individuals per year) and 2) previously published average life expectancies after diagnosis of melanoma-in-situ, local, regional and metastatic disease. Our main outcomes were quality-adjusted life years per person (QALYs), cost per person (in USD 2016), and incremental cost-effectiveness ratios (ICERs).  In the no screening arm, we assumed a sensitivity and specificity of 20% and 85%, respectively, for detection of any stage of melanoma, based on usual care and incidental detection; we assumed a sensitivity and specificity of 50% and 85%, respectively, for screening examinations.  We assumed screening and biopsy costs of $77 and $147, respectively. Health state utilities were based on previous estimates and expert opinion. We conducted one-way sensitivity analyses to examine the influence of key parameters.

Results: Results are shown in the Table. Using base case assumptions, screening every 2 years beginning at age 60 or age 50 each have incremental cost-effectiveness ratios under $100,000 per QALY.  With favorable screening assumptions (sensitivity of no screening: 20%; sensitivity of screening: 90%), ICERs ranged from $11,788/QALY for screening every 5 years starting at age 60 to $55,110/QALY for biannual screening starting at age 50.  With unfavorable screening assumptions (sensitivity of no screening: 50%; sensitivity of screening: 90%), ICERs ranged from $104,586/QALY for screening every 5 years starting at age 60 to $307,272/QALY for annual screening starting at age 50.  Results are insensitive to costs of melanoma treatment but sensitive to costs of screening and biopsy. 

Conclusions:  Screening for melanoma every two years may be cost-effective in white men.  Results are sensitive to degree of difference in sensitivity with screening compared to usual care.