Elsevier

Preventive Medicine

Volume 99, June 2017, Pages 7-12
Preventive Medicine

Economic evaluation of future skin cancer prevention in Australia

https://doi.org/10.1016/j.ypmed.2017.01.013Get rights and content

Highlights

  • A comprehensive skin cancer prevention program can be both life-saving and cost-saving.

  • A potential return of $3.20 can be achieved for every dollar invested.

  • The SunSmart program in Australia provides a benchmark for other countries to consider.

Abstract

Public health programs to reduce the significant burden of skin cancer have been implemented in Australia and around the world. The economic rationale for prevention needs to be kept up-to-date as relevant disease patterns, risk factors and expenditure patterns change through time. The aim of this study was to update and extend the economic credentials for skin cancer prevention in Australia.

Economic evaluations were conducted in 2015 with multiple methods applied, including cost-effectiveness and cost-benefit analysis, multiple study perspectives (‘societal’, ‘health sector’, ‘3rd party funder’) and counterfactual analysis sourced from cancer incidence between 1982 and 2011. Modelled outcomes included ‘cases prevented’, ‘deaths averted’ and ‘health-adjusted life-years’. Cost-benefit Analysis, including productivity impacts in the general economy, was conducted.

With an additional $AUD 0.16 ($USD 0.12) per capita investment into future skin cancer prevention across Australia, 140,000 skin cancer cases would be prevented over the 20 year reference period (2011 to 2030). Depending on study perspective and method, the upgraded program is either dominant (achieving both health gains and cost offsets) or highly cost-effective (health gain at modest net cost). Return on investment (ROI) was $AUD 3.20 per dollar invested, with net social benefit of $AUD 1.43 billion.

The study confirmed the strong economic credentials for skin cancer prevention and provided sound arguments for increased investment in Australia. The reference case analysis provides a useful benchmark for other countries to consider in the design and funding of their prevention programs.

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.

References (55)

  • C.M. Olsen et al.

    Cancers in Australia attributable to exposure to solar ultraviolet radiation and prevented by regular sunscreen use

    Aust Nz J Publ Heal

    (2015)
  • S. Shih et al.

    Economic evaluation of skin cancer prevention in Australia

    Prev. Med.

    (2009)
  • A. Volkov et al.

    Seven-year trends in sun protection and sunburn among Australian adolescents and adults

    Aust Nz J Publ Heal

    (2013)
  • Australian Institute of Health and Welfare

    Health System Expenditures on Cancer and Other Neoplasms in Australia, 2000–01. In., vol. cat. no. HWE 29. (Health and Welfare Expenditure Series no. 22)

    (2005)
  • Australian Institute of Health and Welfare

    Health System Expenditure on Cancer and Other Neoplasms in Australia: 2008–09. In., vol. Cancer series no. 81. Cat. no. 78

    (2013)
  • Australian Institute of Health and Welfare

    Health Expenditure Australia 2011–12. In., vol. Health and welfare Expenditure series no. 50. Cat. no. HWE59

    (2013)
  • Australian Institute of Health and Welfare

    Skin Cancer in Australia. In., vol. Cat. no. CAN 96

    (2016)
  • Australian Institute of Health and Welfare

    Skin Cancer in Australia. In., vol. Cat. No. CAN96

    (2016)
  • Australian Institute of Health and Welfare & Australasian Association of Cancer Registries

    Cancer in Australia: an Overview, 2012. In., vol. Cancer series no. 74. Cat no CAN 70

    (2012)
  • P. Autier et al.

    Is sunscreen use for melanoma prevention valid for all sun exposure circumstances?

    J. Clin. Oncol.

    (2011)
  • E. Azizi et al.

    A graded work site intervention program to improve sun protection and skin cancer awareness in outdoor workers in Israel

    Cancer Causes Control

    (2000)
  • A. Bauer et al.

    Is occupational solar ultraviolet irradiation a relevant risk factor for basal cell carcinoma? A systematic review and meta-analysis of the epidemiological literature

    Brit J Dermatol

    (2011)
  • S. Begg et al.

    The Burden of Disease and Injury in Australia 2003. In. PHE 82

    (2007)
  • S. Begg et al.

    The Burden of Disease and Injury in Australia 2003. In. Welfare AIoHa, Vol. PHE 82

    (2007)
  • M. Boniol et al.

    Cutaneous melanoma attributable to sunbed use: systematic review and meta-analysis

    Br. Med. J.

    (2012)
  • R. Carter et al.

    Could a national skin cancer primary prevention campaign in Australia be worthwhile?: an economic perspective

    Health Promot. Int.

    (1999)
  • A.E. Cust et al.

    Sunbed use during adolescence and early adulthood is associated with increased risk of early-onset melanoma

    Int. J. Cancer

    (2011)
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