Economic evaluation of future skin cancer prevention in Australia
Introduction
Skin cancers are generally classified as cutaneous malignant melanoma (melanoma), non-melanocytic skin cancer (NMSC) or “other skin cancers”. Basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) are the most common types of NMSC; estimated to account for more cases diagnosed than all other cancers combined in Australia (Australian Institute of Health and Welfare, 2016a). As the most common cancer in Australia, the health and economic burden from skin cancers is substantial (Australian Institute of Health and Welfare and Australasian Association of Cancer Registries, 2012). Total expenditure in treating NMSC alone was estimated at 8.1% of all health system spending on cancer. Costing $AUD 511 million in 2012, NMSC is predicted to increase by 22% increase between 2010 and 2015 to over $AUD 700 million (Australian Institute of Health and Welfare, 2013a, Fransen et al., 2012). Melanoma, reported as the third most commonly diagnosed cancer in 2012, involved over $AUD 30 million in health care expenditure in 2001 (Australian Institute of Health and Welfare and Australasian As, Australian Institute of Health and Welfare, 2005). Taking the new and expensive pharmaceutical therapies recently introduced into account, the health care costs were estimated as high as $140 million in 2014 (Melanoma Patients Australia, 2014).
Most importantly, skin cancer is largely preventable and therefore the costs associated with its treatment and management is predominantly avoidable. The relationship between skin cancers and excessive ultraviolet radiation (UV) exposure has been well established by epidemiological data and direct experimental evidence (Kricker et al., 1994, Armstrong and Kricker, 2001, Bauer et al., 2011). Childhood overexposure to UV has been shown to increase the lifetime risk of skin cancer, while unprotected sun exposure later on in life impacts on whether this risk is realized (Marks et al., 1990, Whiteman et al., 2001, Cust et al., 2011, Green et al., 2011a). Natural sunlight and artificial UV exposure are both important to skin cancer development (Cust et al., 2011, Green et al., 2007, Boniol et al., 2012). Public health programs around the world, particularly in Australia, have been implemented to minimize skin cancer premature mortality and morbidity through avoiding excessive sunlight exposure and restricting artificial tanning facility use (Sinclair et al., 2000, Stanton et al., 2004, Dobbinson et al., 2008, Makin et al., 2011, Makin et al., 2013).
Sun protection behaviours such as wearing hats, sunglasses, SPF30 + sunscreen, protective clothing and seeking shade are highly effective in reducing excessive UV exposure (Dobbinson et al., 2008, Makin et al., 2011, Makin et al., 2013, Hill et al., 1992, Dixon et al., 1999, Hill et al., 1993). Population-wide health campaigns and programs, such as the Slip! Slop! Slap! campaign and the SunSmart program, have been implemented in Australia for the past 35 years (Sinclair et al., 2000, Dobbinson et al., 1998, Montague et al., 2001). The achievements of these activities are evident in changing the social attitudes toward tanning and excessive UV exposure (Fransen et al., 2012, Dobbinson et al., 2008, Makin et al., 2013, Livingston et al., 2001). They have demonstrated to be value-for-money and to achieve positive investment returns (Carter et al., 1999, Shih et al., 2009). The economic rationale for prevention, however, needs to be kept up-to-date as relevant disease patterns, risk factors, expenditure patterns, available data, intervention efficacy and suitable methodologies can all change through time.
The aim of the study was to update and upgrade the economic credentials for skin cancer prevention in Australia. We extend a previous analysis to: i) update with the most recent data available on skin cancer incidence (1982– 2011) and program expenditures (1988– 2011); ii) include a cost-benefit analysis; and iii) extend the time horizon to 2030 in a full set of economic evaluations (Shih et al., 2009).
Section snippets
Economic evaluation framework
The economic analyses were conducted in 2015 from a broader ‘societal perspective’, a ‘health sector perspective’ and a ‘government as 3rd party funder’ perspective, with economic methods chosen to match the relevant perspective. The economic methods included cost-effectiveness analysis (CEA) and cost-benefit analysis (CBA).
Economic evaluation was performed by comparing incremental costs in relation to incremental health outcomes achieved by the program. Results were reported as ‘cost per
Results
Implementation of the reference case over 20 year involves an additional $AUD 63 million program cost to government and yields a set of health, financial and economic gains for Australia. Projected health gains include 140,000 cases of skin cancer prevented, 6200 premature deaths averted, 111,000 LYS and 92,600 HALYs. Financial gains include cost offsets in the health sector of over $200 million and productivity gains in the general economy of $2269 million (HCA) or $221 million (FCA).
The full
Discussion
The present study demonstrates a strong economic case for skin cancer prevention that is consistent with findings from previous studies in Australia and United States (Carter et al., 1999, Shih et al., 2009, Kyle et al., 2008, Doran et al., 2016, Gordon et al., 2009). An increase of investment of AUD $0.16 per capita is equivalent to total program cost of AUD $62 million over 20 years (discounted 3% per annum). This contrasts with the enormous skin cancers treatment cost with annual expenditure
Limitations
Based on available epidemiological data we were not able to relate specific levels of investment with specific health outcomes or to distil what particular combination of sun protection activities was more effective than another. Rather, ours was a macro approach that established a ‘reference case’ from an existing program that we could establish as effective and affordable, and then run indicative analysis into the future using the ‘observed/expected’ analysis. Assessment of the upgraded
Conclusions
Results from the updated evaluation are comparable to those of previous evaluations. Our study demonstrates the continuing strong economic credentials of skin cancer prevention. The paper outlines a base per capita investment required to support the population wide risk reduction of skin cancer and provides a benchmark for other countries to consider.
Funding
This work was supported by the National Skin Committee, Cancer Council Australia.
Conflict of interest statement
Author SH was the Manager of Victorian SunSmart Program. Author CS is the Director of the Prevention Division in Cancer Council Victoria and currently the Chair of the National Skin Committee of Cancer Council Australia.
Acknowledgments
The authors are appreciative of the funding and support from the National Skin Committee for this study. Further, the study would not have been possible without the provision of program expenditures and cancer data from Cancer Council Victoria, Cancer Council New South Wales, Cancer Institute New South Wales, Cancer Council Queensland, Cancer Council Western Australia and Cancer Council South Australia.
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Left her position of SunSmart Program Manager.