Skin cancer healthcare impact: A nation-wide assessment of an administrative database

Highlights

• Skin cancer is an important health problem and economic burden for society.

• Its incidence and cost are increasing worldwide.

• Non melanoma skin cancer (NMSC) is about 4 times more costly than melanoma.

• NMSC should not be overlooked in preventative strategies.

Abstract

Background

Skin cancer is an important health concern, with an increasing incidence worldwide.

Objective

To assess the clinical and economic burden of melanoma (MM) and non-melanoma skin cancer (NMSC) at public hospitals in mainland Portugal.

Methods

We used an administrative database containing a registration of all hospitalizations and ambulatory episodes occurred in Portuguese public hospitals between 2011 and 2015. We assessed all episodes with associated diagnoses of MM or NMSC regarding neoplasm location, metastases occurrence, length of stay, in-hospital mortality and hospital costs.

Results

We assessed 15,913 MM and 72,602 NMSC episodes. 14.3% of MM episodes presented with metastases, compared to 1.9% of NMSC episodes. Patients’ median age was lower for MM (66 years) than NMSC (76 years). The trunk was the most common location for MM (32.5%), followed by the lower limbs (26.5%). NMSC presented with higher length of stay than MM (median 5 versus 4 days; p < 0.001), but with lower in-hospital mortality (7.3% versus 11.9%; p < 0.001). MM episodes had higher average hospital costs than NMSC episodes (1197.7 versus 1113.5 €; p < 0.001). Overall, NMSC episodes amounted a total of 80.8 million € in hospital costs versus 19.1 million € for MM episodes.

Conclusion

Skin neoplasms have substantial impact on healthcare services. NMSC is an important contributor to this burden. NMSC underreporting should be tackled and it should not be downplayed in skin cancer preventative strategies.

Introduction

The skin is the most common location of primary malignant neoplasms [1]. In fact, skin cancer has a higher incidence than all other cancers combined [2].

Despite encompassing less than 5% of all skin cancers, melanoma (MM) is responsible in Europe for more than 80% of skin cancer mortality [3], accounting for 1–2% of all cancer deaths [4,5]. According to the European Network of Cancer Registries (ENCR), more than 20 thousand deaths were estimated for MM in Europe in 2008, the largest share (35.5%) for Eastern and Central Europe [5]. Outside Europe, the highest rates of MM incidence are reported in other Caucasian and migrant populations, such as Europeans in Australia and New Zealand, where the annual incidence is more than double the highest rates in Europe [6,7]. Non-melanoma skin cancer (NMSC) incidence is also rising. This condition is often the cause of severe deformation and morbidity. Despite being rarely lethal, NMSC is so common that a relevant number of patients die annually from it, particularly those with advanced squamous cell carcinomas (SSC) [8]. Most NMSC (75–85%) are basal cell carcinomas (BCC), while 15–25% of them are SSC [9].

Overall, not only the incidence, but also the associated costs of skin cancer are increasing. The average annual total cost of skin cancer rose 126.2% in less than ten years in the United States, while the average annual total cost for all other types of cancer rose only by 25.1% [10]. Multiple factors may justify this substantial increment, namely the increase in the incidence of MM and NMSC, awareness of the population with higher diagnostic confirmations and the development of expensive medical treatments. Costs associated with skin cancer treatment are expected to continue to rise, increasing its economic impact for health services [[11], [12], [13], [14], [15]].

Notwithstanding its frequency and importance, the epidemiology and health services impact of skin cancer remains insufficiently studied. Therefore, this study aims at assessing the clinical epidemiology and economic burden of MM and NMSC – particularly concerning their hospital costs, length of stay and in-hospital mortality – by analyzing an administrative database containing a registration of all public hospital episodes occurring in mainland Portugal from 2011 to 2015.