An estimate of the cost of treating mlanoma disease in the state of Sao Paulo - Brazil

Abstracts

FUNDAMENTOS: O impacto econômico do diagnóstico e do tratamento do melanoma cutâneo não tem sido analisado no Brasil. Uma vez que crescem tanto a incidência do câncer de pele quanto a preocupação com ele, é importante que isto seja avaliado. OBJETIVO: O objetivo deste trabalho foi estimar o custo direto de diagnosticar e tratar em seus diversos estádios o melanoma cutâneo em número de casos ocorridos no Estado de São Paulo, entre 2000 e 2007. MÉTODOS: Como modelo de procedimento, foi utilizado o projeto diretriz (Clinical Practice Guidelines in Oncology), editado pelo National Comprehensive Cancer Network (NCCN) e adequado aos procedimentos da Fundação SobecCan - Hospital do Câncer de Ribeirão Preto - SP. Os custos estimados se baseiam nos valores do tratamento médico pagos pelo setor público (Sistema Único de Saúde - SUS) e pelo setor privado (convênios) em 2007. Houve 2.740 casos diagnosticados e estadiados no Estado de São Paulo no período estudado. RESULTADOS: O custo total de tratamento dos melanomas malignos diagnosticados no estádio inicial, em valores de 2007, foi estimado em R$ 33.012.725,10 para o SUS e R$ 76.133.662,80 para os convênios.Os estádios iniciais 0, I e II da doença compreendem aproximadamente 4,2% (SUS) e 1, 3% (convênios) do custo total; os estádios III e IV consomem 95,8% e 98,7% do custo total, respectivamente. CONCLUSÃO: Os resultados apresentados reforçam o argumento de que o diagnóstico do melanoma cutâneo em seus estádios iniciais reduz os custos de tratamento, gerando considerável economia tanto para o sistema público de saúde (SUS) quanto para o sistema privado (convênios).

Melanoma; Melanoma; Melanoma; Neoplasias Cutâneas; Neoplasias Cutâneas; Raios Ultravioleta

INVESTIGATION

An estimate of the cost of treating melanoma disease in the state of Sao Paulo – Brazil

Reynaldo José Sant’Anna Pereira de Souza^I; Adriana Prest Mattedi^II; Marcelo Lacerda Rezende^III; Marcelo de Paula Corrêa^IV; Etiene Marques Duarte^V

^IMaster. Fundação SOBECCan – Hospital do Cancer de Ribeirão Preto (SP), Hospital do Cancer de Franca – Franca (SP), Brazil

IIMaster and Ph.D. Department of Mathematics and Computer Sciences, Instituto de Ciências Exatas (DMC/ICE), Universidade Federal de Itajubá (UNIFEI) – Itajubá (MG), Brazil

IIIMaster and Ph.D. Department of Exact Sciences (DCE) - Universidade Federal de Alfenas – Alfenas – (MG), Brazil

IVMaster and Ph.D. Institute of Natural Resources (IRN), Universidade Federal de Itajubá (UNIFEI) – Itajubá (MG), Brazil

VOngoing Business Administration undergraduate studies, Universidade Federal de Itajubá (UNIFEI) – Itajubá (MG), Brazil

^{Mailing Address}

ABSTRACT

OBJECTIVE: The purpose of this study was to estimate the direct cost of diagnosing and treating melanoma disease in Sao Paulo (Brazil) between the years 2000 and 2007.

METHODS: The project Clinical Practice Guidelines in Oncology was used, adapted to the proceedings of SOBECCan Foundation. The estimated costs were based on the values of the medical treatment paid by the Brazilian National Health System (SUS) and private healthcare insurance companies (PHIC) in 2007.

RESULTS: The total cost was estimated in R$33,012,725.1 (SUS) and R$76,133,662.8 (PHIC). Stages 0, I and II comprised about 4.2% (SUS) and 1.3% (PHIC) of the total cost; stages III and IV amounted to 95.8% and

98.7% of the total cost, respectively.

CONCLUSION: The diagnosis of malignant melanoma in its initial stages reduces treatment costs generating considerable savings of resources for both National Health System and private healthcare insurance companies.

Keywords: Melanoma; Melanoma/Economics; Melanoma/Therapy; Skin Neoplasms; Skin Neoplasms/Economics; Ultraviolet Rays

INTRODUCTION

Melanoma originates from melanocytes, skin cells that produce a pigment named melanin, which provides skin protection against the damage caused by ultraviolet radiation (UV). The development of melanoma is a consequence of loss of the genetic mechanisms to control cells, caused primarily by UVA and UVB radiations. However, acral lentiginous melanoma, which comprises approximately 10% of the cases of melanoma, normally detected on the palms of the hands, foot soles, subungal region and fingertips, may present a different growth pattern from the other types, probably not influenced by UV radiation exposure ¹.

The three main types of skin cancer are basal cell carcinoma (BCC), squamous cell carcinoma (SCC), which form the non-melanoma skin cancer group, and cutaneous melanoma (CM).

BCC, according to data by Instituto Nacional de Cancer (INCA), amounts to approximately 70% of the cases of skin cancer in Brazil. It is the most frequent and least severe type, rarely disseminated to other organs. However, it may destroy the tissues around it, reaching cartilages and bones. SCC, the second most frequent skin cancer type, amounts to approximately 25% of the cases, can be disseminated to lymphatic ganglia and other organs, which leads to metastases. Even though mortality rates to BCC and SCC are low, these types of cancer may lead to physical deformities if left untreated. CM, despite its lowest occurrence (± 5%), is the most aggressive and responsible for approximately 75% of all deaths caused by skin cancer. This type of cancer can easily disseminate to the lymphatic system and other internal organs.

Early diagnosis is important to all cases, but especially to CM, because in situ melanoma may be cured, but once there is a metastasis, it is practically fatal. According to Berwick et al (1996)², in a control case based on the population, a self-examination of the skin may reduce death by skin cancer thanks to early detection. Rocha et al (2002)³ have also concluded that early diagnosis seems to significantly contribute to reducing the morbidity and mortality of the disease. In cases of BCC and SCC, treatment is mainly surgical and it also produces scars and the possibility of reaching neighboring structures.

The total number of skin cancers, melanoma or not, has been quickly increasing in the world ^4,5. In Brazil, according to INCA data, the most frequent type of cancer in the country is skin cancer, corresponding to almost 30% of estimated cases in 2006 ⁶. These data may be underestimated, as reported by INCA, owing to the fact that many suspected lesions are excised without formal diagnosis or in private clinics.

Another element of concern is the fact that the growth rate of skin cancer has showed an increase of approximately 113% between 2001 and 2006, second only to prostate cancer. It is important to emphasize that 2004 data were not available for the survey and are not included in the present analysis. Following this trend, there will be about 280 cases per 100,000 inhabitants in 2010 and approximately 595.92 cases per 100,000 inhabitants in 2015 ⁷. Moreover, even though it has low incidence (4% of skin cancer cases), CM is associated with significant morbidity, owing to its high likelihood of developing metastases ⁶. These reasons justify the campaigns and investments made to prevent skin cancer that are organized by physicians and the public health system.

Risk factors for development of skin cancer may be both genetic and environmental. The most significant environmental cause is excessive sun exposure, especially during the first 20 years of life ⁸. People with some physical characteristics, especially those with light hair and eye color, are at higher risk of developing skin cancer ⁹. In Brazil, most of these cases occur in the south and southeast regions of the country, where the population is predominantly Caucasian and more susceptible to the influence of high levels of UV radiation ¹⁰.

Black-skin people, owing to the darker color of their skin, tend to overlook initial lesions and diagnosis is normally made in advanced stages of the disease. Moreover, this population is highly subject to acral lentiginous melanoma, not associated with UV radiation exposure, and more common in the northeast region of the country.

Moreover, there is a common sense that the predominant social-economic and cosmetic standard is to be tanned. Until the Industrial Revolution, the poorest groups of the population worked in agriculture and were exposed to the sun, whereas the higher income groups maintained their skin very fair as a sign of social status. With the opening of manufacturing plants, rural workers migrated to the plants and the pattern was inverted, which now means that tanned look equals more favorable social and economic status. This culture, as part of a tropical country, favors outdoor activities and sports and induces to excessive ultraviolet sun exposure especially among youngsters. Research studies show that among young people, despite knowledge about the risks of excessive exposure to sunlight and how to protect the skin, they maintain the prevalent habit of intentionally exposing to the sun ¹¹. According to some authors, the exposure occurs not only to become tanned, but also because no one is concerned about protecting the skin during daily activities. At the same time, rural and informal workers can be frequently seen and they are a risk group for the disease because they are not aware of the effects of sunlight exposure or have difficulties owing to their social-economic restrictions.

Studies have shown that in the United States, CM is diagnosed most of the time in adults aged between 40 and 50 years ¹². In Brazil, the Database of the National Health System (DATASUS) shows that the highest incidence of CM is over the age of 70 years ¹³, that is, in approximately 0.0021% of the population. However, it is possible to see a significant number of diagnoses made in the age range 10 to 29 years.

Thus, considering that the incidence and the concern with skin cancer are growing, it is important to assess the economic impact of exam, diagnosis, treatment and follow-up of CM. The purpose of the present study was to survey the costs related with management of CM in patients at different disease stages under the perspective of two payers: the public health system (SUS) and private healthcare insurance companies, so as to assess the impact of the disease over them. As case report, we will present the data referring to the State of Sao Paulo between January 2000 and December 2007.

METHODS

The study of the costs of managing skin cancer will be carried out in some phases, and the first one is the estimate of CM treatment costs. A model including the probability of occurrence and different stages was created using the data from the State of Sao Paulo. The next step was to expand the study to the whole country and include the cases of non-melanoma skin cancer. For better accuracy of the model, we will build a geographical database. The database will contain information about regional history of the disease, social-economic data about the patients, effectiveness of treatment at different stages and other information that may be added, as required. Finally, we will include the cost-effectiveness calculation ¿ in the model.

In the present study, we considered first the treatment of one single patient, treated under the perspective of SUS and private healthcare system. Therefore, considering the public system as payer, financial information was provided by the Table of Fees per Procedure by SIA/SUS and SIH/SUS (outpatient and inpatient, respectively) ^14,15, and the private healthcare system, using the table of procedures AMB92. The unit costs were estimated by product of unit cost for each procedure based on the amount of each individual item. Then, we calculated the total values for each stage, considering the number of cases classified in the different groups. Data were expressed in reais (R$), values of 2007, both for payment by SUS and by private system, for which there is also the CH value (Coefficient of Medical Fees), a unit used by the Brazilian Medical Association (AMB) to quantify each medical procedure for compensation purposes. In the present study, the value of CH was R$0.28 which corresponds to the average amount paid by private companies for medical procedures performed by Fundação SOBECCan – Hospital do Cancer de Ribeirão Preto – SP.

To standardize the analysis of treatments, we assumed that all new patients with suspicion of skin cancer would undergo initial diagnosis that comprised the costs for: a) medical initial visit; b) excision biopsy procedure; and c) pathology report. Based on this procedure, the model had two possibilities: the result could be non-melanoma skin cancer (not addressed in the present study), or CM skin cancer. In case of CM, the simplified flow chart with procedures for diagnosis and treatment was created to estimate the cost of treatment and it is presented in Figure 1. The model of procedure was based on the guidelines of Clinical Practice Guidelines in Oncology for melanoma, edited by National Comprehensive Cancer Network (NCCN)¹⁶ which was appropriate to the procedures of Fundação SOBECCan - Hospital do Cancer de Ribeirão Preto – SP. The first level of the model presented a percentage of patients in the many different stages. The data came from Fundação Oncocentro de São Paulo (FOSP): 3,187 diagnoses of CM in the state of Sao Paulo between January 2000 and December 2007, with 2,740 cases already classified into stages I, II, III and IV according to the staging criteria by the American Joint Committee on Cancer (AJCC), and 447 cases were not staged.

Treatment choice for CM depended on cancer extension and staging. According to the methodology defined by AJCC: stage Ia: localized, thickness = 0.75 mm; stage Ib: localized, thickness between 0.76mm and 1.5mm; stage IIa: localized, thickness between 1.51 mm and 4.0 mm; stage IIb: localized, thickness > 4.0 mm; stage III: transit metastasis or only regional involvement of nodule; and stage IV: presence of distant metastasis.

To calculate the cost, we considered the standard procedures for diagnosis, management and follow-up of patients with CM. They included the costs with medical visits, laboratory tests, excision biopsy, anatomical pathology examination, imaging exams for staging (x ray, CT scan), surgical procedure and pre-surgical tests, medication-based treatment of melanoma (interferon, chemotherapy), and palliative radiotherapy in stage IV.

The analysis did not include alternative therapies or radiotherapy that can be started in different situations (residual disease, inoperable lesions, elderly or frail patient, etc), hospital fees, different drugs not directly related with CM treatment nor indirect costs such as the time spent by the patient in treatment or non-productive time due to leave from work. Moreover, we did not include the costs with suspected lesions that were not diagnosed as CM.

Given that the purpose of the study was to estimate the direct cost of CM treatment at different stages, we used calculation of costs produced by the patient in one year of treatment and/or follow-up, without taking into account death during this period. These specificities should be detailed later when we proceed with cost-effectiveness calculations.

Once again, it is important to emphasize that these values do not necessarily reflect all involved costs, because they encompass the charges for service provision of a part of the healthcare system. For this reason, values presented here probably underestimate the real economic impact of the disease.

RESULTS

In this study, we considered 3,187 cases of CM diagnosed in the state of Sao Paulo between January 2000 and December 2007. Among the 3,187 cases, 447 were not staged and for this reason were not included in the cost calculation.

The direct unit cost of CM treatment by stage used by SUS and the private system is presented in Table 1. In such data, we can see the difference between the value of treatment cost in the first three stages (0, I and II) and the two last stages. It occurs because stages III and IV require high cost medication treatment. All stages presented an investigation and diagnostic procedure and this is the time when staging is defined. Next, except for stage 0, a second surgery is sometimes required to expand the surgical margins and ensure that the whole affected tissue has been removed. Stages III and IV require medical treatment after surgery, generally with interferon if stage III, and chemotherapy if stage IV.

In Table 1 we can see that the number of cases of CM and the total and average cost of treatment by stage. Once again, the high values of stages III and IV stand out. This fact can be clearly seen in Graph 1, in which participation of expenses with treatment in each stage in relation to the total is presented in details.

The average annual cost with treatment per patient, considering 2,740 cases, based on amounts paid by SUS was R$13,062.40 ±16,848.60 and by private system was R$26,668.30 ±42,749.59. The high standard deviation values for both systems result from the large differences in treatment costs between the three initial stages and the last two. It is important to emphasize the total values spend both by SUS (R$33,012,725.10) and the private system (R$76,133,662.80). They are translated into annual average costs of R$4,126,590.60 and R$9,516,707.90, respectively.

This aspect is made even clearer in Table 2, where we can see the number of skin cancer staged 0 and I, which can be treated with the treatment cost of one single case of stages III or IV. Through these values, the importance of preventing skin cancer becomes evident.

Graph 2 presents the proportion of costs of treatment phases in each stage in the two payment systems: (a) public and (b) private. We can see that as severity of CM increases, the costs increase with type of treatment required: stage 0 presented the higher cost of diagnosis; stages I and II, the higher cost of surgical treatment, and stages III and IV have the predominance of drug treatment.

DISCUSSION

Most costs with CM – more than 95% - result from treatment of more advanced stages (III and IV), considering the cost of medication required to treat the disease stages. In these cases, the cost of treatment of one single patient in these stages may cover the costs of many treatment courses at initial stages. It is evident that prevention is important to save lives and for financial reasons.

It is important to emphasize that diagnosis of cutaneous melanoma at initial stages (0, I and II) saves lives and also reduces the cost of treatment generating considerable savings of resources for both the public system (SUS) and the private healthcare system. The savings could be employed in programs of prevention and early diagnosis of skin cancer or be invested in research studies of new techniques and medications to treat these people.

CONCLUSION

It is a common sense that skin cancer generates direct and indirect costs for governments, private healthcare plans and a significant number of patients. In this study, the costs of treatment of cutaneous melanoma, considering the procedures recommended by the scientific literature and the practice at Fundação SOBECCan – Hospital do Cancer de Ribeirão Preto – SP, proved to be high, especially in managing stages III and IV disease.

It is also important to mention, as emphasized by Tsao et al (1998), that complete analysis of the cost of treatment of skin cancer depends on the definite probability of the natural history of the disease, development of skin test, effectiveness of treatment in different stages, risks of complications, competitive risks of mortality, and loss of income resulting from death or morbidity of treatment. To run a complete model it would be necessary to have a complete database with different variables that are not available right now. To build this database and develop a more reliable method we will put into practice the next steps of this research study.

REFERENCES

Conflict of interest: None

Financial funding: None

How to cite this article: Souza RJSP, Mattedi AP, Rezende ML, Corrêa MP, Duarte EM. Estimativa do custo do tratamento de câncer de pele tipo melanoma no Estado de São Paulo – Brasil. An Bras Dermatol. 2009;84(3):237-43.

• 1. Liu Z-J, Herlyn M. Molecular biology of cutaneous melanoma. In: DeVita Jr VT, Lawrence TS, Rosenberg SA. Cancer: principle & practice of oncology. 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2005. p. 1746-53
• 2. Berwick M, Begg CB, Fine JA, Roush GC, Barnhill RL. Screening for cutaneous melanoma by skin self-examination. J Natl Cancer Inst. 1996;88:17-23
• 3. Rocha FP, Menezes AMB, Almeida Junior HL, et al Especificidade e sensibilidade de rastreamento para lesões cutâneas pré-malignas e malignas. Rev Saude Publica. 2002;36:101-106
• 4. Balch CM, Buzaid AC, Soong SJ, Atkins MB, Cascinelli N, Coit DG, et al Final version of the American Joint Committee on cancer staging system for cutaneous melanoma. J Clin Oncol. 2001;19:3635-48
• 5. Diepgen TL, Mahler V. The epidemiology of skin cancer. Br J Dermatol. 2002;146(Suppl 61):S1-6
• ⁶
  Brasil, Ministério da Saúde. Secretaria de Atenção à Saúde. Instituto Nacional do Câncer. Coordenação de Prevenção e Vigilância: estimativa 2006: incidência de câncer no Brasil. 2005;1-98
• ⁷
  Inca.gov.br [homepage]. Estimativas da incidência e mortalidade por câncer. [acesso 4 Abril 2007]. Disponível em: http://www.inca.org.br
• 8. Chinni DA, Schwartz JL, Keilman LJ, et al Early melanoma detection: what is the role of the advanced practice nurse? The Internet Journal of Advanced Nursing Practice. 2003;5
• 9. Barnes L. Sun education in Ireland. Clin Dermatol. 1998;16:517-8
• 10. Corrêa MP, Dubuisson P, Plana-Fattori A. An overview of the ultraviolet index and the skin cancer cases in Brazil. Photochem Photobiol. 2003;78:49-54
• 11. Souza SRP, Fischer FM, Souza JMP. Bronzeamento e risco de melanoma cutâneo: revisão da literatura. Rev Saúde Pública. 2004;38:588-98
• 12. Tsao H, Rogers GS, Sober AJ. An estimate of the annual direct cost of treating cutaneous melanoma. J Am Acad Dermatol. 1998;38:669-80
• ¹³
  W3. datasus.gov.br/datasus/datasus.php [homepage]. Informação de Saúde: Morbidade hospitalar do SUS – por local de internação – Brasil. [cited 4 Abril 2007]. Disponível em: http://tabnet.datasus.gov.br/cgi/tabcgi.exe?sih/cnv/miuf.def
• 14. W3. datasus.gov.br/datasus/datasus.php [homepage]. Tabela de procedimentos SIH/SUS, Janeiro de 2007. [acesso 2007 April 4]. Disponível em: http://W3.datasus.gov.br/siasih/siasih.php
• 15. W3. datasus.gov.br/datasus/datasus.php [homepage]. Tabela de procedimentos SIA/SUS, janeiro de 2007. [acesso 4 abril 2007]. Disponível em: http://W3.datasus.gov.br/siasih/siasih.php
• ¹⁶
  National Comprehensive Cancer Network (NCCN): Clinical Practice Guidelines in Oncology – melanoma. 2006;V.2.2006:1-33

Publication Dates

• Publication in this collection
  04 Aug 2009
• Date of issue
  July 2009

History

• Accepted
  12 Sept 2008
• Received
  12 Sept 2008