Extending Medicare Coverage for Preventive and Other Services (2000) / Chapter Skim
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3 Screening for Skin Cancer
3 Screening for Skin Cancer
Pages 38-62
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From page 38... ...
Clinical screening~xamination by a physician or other Pained individual of the skin of an For melanoma, warning symptoms include new or changing pigmented spots that are asymmetrical, larger than 6 mm, irregular in border, or varied in color including blue, black, or gray. For nonmelanoma skin cancer, warning symptoms include the appearance of a new spot, bump, or sore that does not heal or go away in about two weeks, and may or may not bleed or crust.
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From page 39... ...
In addition, screening is often promoted as a way of reducing the overall costs associated with treating disease, especially late-stage disease. Nonetheless, when claims about the benefits of particular screening programs are subjected to systematic evaluation, the evidence supports some but is negative, mixed, limited, or otherwise inadequate to support others (see, e.g., Eddy, 1991; Russell, 1994; USPSTF, 1996~.2 As controversies over assessments of breast cancer screening for women ages 40 to 49 demonstrate, conclusions that the evidence does not clearly support screening for a particular disease can generate considerable controversy, given the understandable hopes that screening will prevent or reduce the mortality, disability, arid other suffering caused by the disease (see, e.g., Eddy, 1997; Ransohoff and Harris, 1997; Taubes, 1997a,b)
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From page 40... ...
skin cancer screening may rely on a case-finding strategy, when a person seeing a health care professional for another reason is offered a total skin examination (or a partial skin examination with referral to a specialist depending on the findings)
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From page 41... ...
Also excluded from the definition of screening are Medicare-covered follow-up visits and skin examinations for patients previously diagnosed and treated for skin cancer or other conditions that put them at higher risk for skin cancer. In contrast to a new program of clinical skin cancer screening, all these services are considered part of usual patient care.
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From page 42... ...
As explained earlier, this report provides only estimates of costs to Medicare and not others, and it does not include formal assessment of the cost-effectiveness of skin cancer screening compared to other interventions (e.g., promotion of skin self-examination)
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From page 43... ...
. POPULATION BURDEN OF DISEASE The skin cancers considered here are melanoma, basal cell carcinoma, and squamous cell carcinoma.6 The latter two are often lumped together as nonmelanoma skin cancers, which also include other, far less common skin malignancies such Kaposi's sarcoma and cutaneous T-cell lymphoma.
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From page 44... ...
SEER data also show that more than 80 percent of melanomas are diagnosed while still local. Nonmelanoma Skin Cancers Basal cell carcinoma and squamous cell carcinoma are the most common skin cancers, accounting for about one million new cases a year and about 1,900 deaths (ACS, 1999a)
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From page 45... ...
It is usually curable if detected early but may cause death, functional impairment, or severe disfigurement if neglected. Squamous cell carcinoma of the skin accounts for about one-fifth of all skin cancers and most of the deaths from nonmelanoma skin cancer (ACS, 1999a)
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From page 46... ...
For melanoma that has spread beyond the skin and lymph nodes, treatment is primarily palliative, aimed at relieving pain and other symptoms rather than at improving long-term survival. Nonmelanoma Skin Cancers Most nonmelanoma skin cancers can be successfully treated with one of several kinds of surgical procedures including surgical excision, cryosurgery (which uses liquid nitrogen to kill cancer cells)
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From page 47... ...
If nothing suspicious is found during the skin examination, the result of the screening examination is described as negative. If a clinician identifies a mole or other lesion suspicious for melanoma or nonmelanoma skin cancer, the examination is considered positive.
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From page 48... ...
Among those in the rule-out category who had a biopsy, an additional 234 cases of melanoma were identified, but finding those cases required biopsies for additional 2,316 disease-free individuals. Two commonly used measures of screening test accuracy specificity and sensitivity—cannot usually be computed for skin cancer screening studies because only the suspicious lesions that are detected are biopsied, and people with negative screening result are not followed.
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From page 49... ...
If a new program of skin cancer screening were to be adopted, a number of practical questions would anse. One is how accurate primary care clinicianswho form the hont-line in most screening programs are likely to be in identifying skin cancers or skin cancer risk factors.
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From page 50... ...
In an effort to improve the yield and reduce the cost of skin cancer screening, some studies have examined screening targeted to high-risk individuals identified by a patient history or self-administered questionnaire. These studies tend to show that individuals are more accurate in reporting some risk factors (hair color, freckles, number of moles)
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From page 51... ...
Those who test positive during screening but actually have no disease can suffer harms including anxiety, inconvenience, explicit or covert discrimination by insurers or employers, and unnecessary further testing and treatment. Thus, one factor cited in recommendations against prostate cancer screening is the high rate of false positives and the significant risks of impotence, incontinence, and other harms associated with surgical treatment (USPSTF, 1996~.
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From page 52... ...
The committee also found no case-control studies of the effectiveness of clinical skin cancer screening in reducing mortality or morbidity. Lacking direct evidence of a link between skin cancer screening and better outcomes, the committee searched for indirect evidence.
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From page 53... ...
The most limited option would be to pay for a single screening examination in combination with education about skin selfexamination. Whatever the frequency of screening, skin cancer screening could be incorporated in a periodic preventive services visit that also included other recommended preventive services.
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From page 54... ...
As summarized in Box 3-1 and explained below, for the five-year period 2000 to 2004, net estimated costs to Medicare range from about $150 million for the most limited screening scenario to about $900 million dollars for the most expansive. The committee's estimates of Medicare costs are based on a series of assumphons, some of which have supporting evidence or data but others of which ~ -- ~-~-~-~BOX~3 ~1~-~-~ ~ ~~ ~~ ~~ i ~~ ~ ~~I'd ~ ~ ~ ~ ~ ~ ~ ~ .~ ~ ~ ~ ~ ~ ~ ~ ~ ~ I'd ~ ~ ~ ~ ~ ~ ~ ~ : ~~ ': ~~-~ ~':~- ~~ ~~.~ ~ ~ ~~.~ ~ ~ ~ I
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From page 55... ...
The estimates are intended to suggest the order of magnitude of the costs to Medicare of extending coverage, but they could be considerably higher or lower than what Medicare might actually spend were coverage policies changed. The tables in Appendix E allow readers to vary some of the committee's assumptions and calculate alternative estimates.~5 The unit cost of skin cancer screening services (physician visits and diagnostic biopsies)
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From page 56... ...
For a physician, discussing skin cancer screening and doing a risk assessment or skin examination could add several minutes to office visits that are often scheduled for less than 15 minutes.
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From page 57... ...
The result was an estimated $29,170 expended per year of life saved, a figure not greatly different from several other cancer screening strategies. It is important to note that the assumptions of the analysis are significantly different than those used here, namely, that screening would in fact detect melanomas at earlier stages leading to earlier and less costly treatment.
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From page 58... ...
Findings After reviewing the literature, considering the discussion at its workshop, and drawing on its members' judgment, the committee reached several findings relevant to decisions about coverage of a new program for skin cancer screening for Medicare beneficiaries. The first findings listed below relate to the assessment criteria depicted in Figure 3-1.
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From page 59... ...
Basal cell and squamous cell carcinoma are relatively common among older people. Squamous cell carcinoma is sometimes lethal and both can cause disfigurement or functional impairment.
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From page 60... ...
Because basal cell carcinoma and squamous cell carcinoma are highly treatable and rarely lethal, it is unlikely that a new program of screening asymptomatic people could appreciably improve survival rates. Direct evidence is not available on the effect of screening on morbidity and disfigurement from these conditions.
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From page 61... ...
Such research would help answer questions about how quickly different kinds of melanomas progress in different risk groups and about how likely it is that earlier detection of disease through a new program of clinical screening would make a difference in outcomes. More research would also be useful to understand how frequently and how quickly actinic keratoses develop into squamous cell carcinoma and what factors predict such progression.
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From page 62... ...
Medicare already covers skin examination and testing by primary care physicians and dermatologists prompted by patient concern about a skin abnormality or by incidental physician discovery of an abnormality during a visit for other purposes. Further, dermatological and other organizations should continue skin cancer educational programs for people of all ages, including programs that encourage people to limit sun exposure and inform themselves about skin cancer risk factors and warning signs, especially those for melanoma.
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