Applied Health Economics and Health Policy

, Volume 16, Issue 2, pp 235–242 | Cite as

A National Budget Impact Analysis of a Specialised Surveillance Programme for Individuals at Very High Risk of Melanoma in Australia

  • Caroline G. Watts
  • Sally Wortley
  • Sarah Norris
  • Scott W. Menzies
  • Pascale Guitera
  • Lisa Askie
  • Graham J. Mann
  • Rachael L. Morton
  • Anne E. Cust
Original Research Article



Specialised surveillance using total body photography and digital dermoscopy to monitor people at very high risk of developing a second or subsequent melanoma has been reported as cost effective.


We aimed to estimate the 5-year healthcare budget impact of providing specialised surveillance for people at very high risk of subsequent melanoma from the perspective of the Australian healthcare system.


A budget impact model was constructed to assess the costs of monitoring and potential savings compared with current routine care based on identification of patients at the time of a melanoma diagnosis. We used data from a published cost-effectiveness analysis of specialised surveillance, and Cancer Registry data, to estimate the patient population and healthcare costs for 2017–2021.


When all eligible patients, estimated at 18% of patients with melanoma diagnosed annually in Australia, received specialised surveillance rather than routine care, the cumulative 5-year cost was estimated at $93.5 million Australian dollars ($AU) ($US 64 million) for specialised surveillance compared with $AU 120.7 million ($US 82.7 million) for routine care, delivering savings of $AU 27.2 million ($US 18.6 million). With a staggered introduction of 60% of eligible patients accessing surveillance in year 1, increasing to 90% in years 4 and 5, the cumulative cost over 5 years was estimated at $AU 98.1 million ($US 67.2 million), amounting to savings of $AU 22.6 million ($US 15.5 million) compared with routine care.


Specialised melanoma surveillance is likely to provide substantial cost savings for the Australian healthcare system.


Data Availability Statement

The model inputs used in the budget impact analysis and the model structure can be found in Tables 1–3 and in Figs. 2–3, respectively, in the ESM and are reprinted with permission. © 2017 American Society of Clinical Oncology. All rights reserved. The data related to the standard care arm were made available to the authors from The Sax Institute’s 45 and Up study, Cancer Institute NSW and NSW Health. Restrictions apply to the availability of these data, which were used under license for the current study and therefore are not freely available to the public. The data from specialised surveillance in the high-risk clinic are potentially identifiable. To maintain participant privacy, the Human Research Ethics Committee has restricted their use to the immediate study investigators. Excel tables used to calculate the budget impact analysis, provided to the reviewers, are available from Dr. Caroline Watts upon reasonable request.


The authors thank Caro Badcock for statistical assistance..

Author contributions

CW was responsible for the conception and planning of the manuscript, analysis and interpretation of the data, and the drafting and critical revision of the manuscript. SW, SN, SM, PG, LA, GM, RM and AC were responsible for the conception and planning of the manuscript, interpretation of the data, and critical revision of the manuscript.

Compliance with Ethical Standards


CGW was funded through an NHMRC Program Grant APP1093017. AEC was supported by Career Development Fellowships from the NHMRC (#1063593) and Cancer Institute NSW (#15/CDF/1-14), RLM was supported by an NHMRC Fellowship (#105466). GJM and SWM were supported by Cancer Institute NSW Translational Program Grant (10/TPG/1-02).

Conflict of interest

CGW, SW, SN, SWM, PG, LA, GJM, RLM and AEC have no conflicts of interest.

Supplementary material

40258_2017_368_MOESM1_ESM.docx (378 kb)
Supplementary material 1 (DOCX 378 kb)


  1. 1.
    Balch CM, Gershenwald JE, Soong S, Thompson JF, Atkins MB, Byrd DR, et al. Final version of 2009 A.J.C.C melanoma staging and classification. J Clin Oncol. 2009;27(36):6199–206.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Watts CG, Dieng M, Morton RL, Mann GJ, Menzies SW, Cust AE. Clinical practice guidelines for identification, screening and follow-up of individuals at high risk of primary cutaneous melanoma: a systematic review. Br J Dermatol. 2015;172(1):33–47.CrossRefPubMedGoogle Scholar
  3. 3.
    Australian Institute of Health and Welfare (AIHW). Cancer in Australia. 2017.Google Scholar
  4. 4.
    Moloney F, Guitera P, Coates E, Haass N, Ho K, Khoury R, et al. Detection of primary melanoma in individuals at extreme high risk: a prospective 5 year follow-up study. JAMA Dermatol. 2014;150(8):819–27.CrossRefPubMedGoogle Scholar
  5. 5.
    Watts CG, Cust AE, Menzies SW, Mann GJ, Morton RL. Cost-effectiveness of skin surveillance through a specialized clinic for patients at high risk of melanoma. J Clin Oncol. 2017;35(1):63–71. Scholar
  6. 6.
    Sullivan SD, Mauskopf JA, Augustovski F, Caro JJ, Lee KM, Minchin M, et al. Budget impact analysis—principles of good practice: report of the ISPOR 2012 budget impact analysis good practice II task force. Value Health. 2014;17(1):5–14.CrossRefPubMedGoogle Scholar
  7. 7.
    Watts CG, Madronio CM, Morton RL, Goumas C, Armstrong BK, Curtin A, et al. Diagnosis and clinical management of melanoma patients at higher risk of a new primary melanoma: a population-based study in New South Wales. Australia: Aust J Dermatol; 2016. Scholar
  8. 8.
    Australian Bureau of Statistics (ABS). Consumer Price Index Inflation Calculator. 2017.Google Scholar
  9. 9.
    Organisation for Economic Co-operation and Development (OECD). Purchasing Power Parities (PPP) indicator. 2017.Google Scholar
  10. 10.
    Ferrone CR, Porat LB, Panageas KS, Berwick M, Halpern AC, Patel A, et al. Clinicopathological features of and risk factors for multiple primary melanomas. JAMA. 2005;294(13):1647–54. Scholar
  11. 11.
    Newton JA, Bataille V, Griffiths K, Squire JM, Sasieni P, Cuzick J, et al. How common is the atypical mole syndrome phenotype in apparently sporadic melanoma? J Am Acad Dermatol. 1993;29(6):989–96. Scholar
  12. 12.
    Bataille V, Grulich A, Sasieni P, Swerdlow A, Bishop JN, McCarthy W, et al. The association between naevi and melanoma in populations with different levels of sun exposure: a joint case–control study of melanoma in the UK and Australia. Br J Cancer. 1998;77(3):505–10.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Aitken JF, Duffy DL, Green A, Youl P, MacLennan R, Martin NG. Heterogeneity of melanoma risk in families of melanoma patients. Am J Epidemiol. 1994;140(11):961–73.CrossRefPubMedGoogle Scholar
  14. 14.
    Hansson J, Bergenmar M, Hofer PÅ, Lundell G, Månsson-Brahme E, Ringborg U, et al. Monitoring of kindreds with hereditary predisposition for cutaneous melanoma and dysplastic nevus syndrome: results of a Swedish preventive program. J Clin Oncol. 2007;25(19):2819.CrossRefPubMedGoogle Scholar
  15. 15.
    Hayward NK. Genetics of melanoma predisposition. Oncogene. 2003;22(20):3053–62. Scholar
  16. 16.
    Goldstein AM, Tucker MA. Genetic epidemiology of familial melanoma. Dermatol Clin. 1995;13(3):605.PubMedGoogle Scholar
  17. 17.
    Pomerantz H, Huang D, Weinstock MA. Risk of subsequent melanoma after melanoma in situ and invasive melanoma: a population-based study from 1973 to 2011. J Am Acad Dermatol. 2015;72(5):794–800. Scholar
  18. 18.
    Balamurugan A, Rees JR, Kosary C, Rim SH, Li J, Stewart SL. Subsequent primary cancers among men and women with in situ and invasive melanoma of the skin. J Am Acad Dermatol. 2011;65(5 SUPPL. 1):S69–77.PubMedGoogle Scholar
  19. 19.
    Aitken J, Welch J, Duffy D, Milligan A, Green A, Martin N, et al. CDKN2A variants in a population-based sample of Queensland families with melanoma. J Natl Cancer Inst. 1999;91(5):446–52. Scholar
  20. 20.
    Eliason MJ, Larson AA, Florell SR, Zone JJ, Cannon-Albright LA, Samlowski WE, et al. Population-based prevalence of CDKN2A mutations in Utah melanoma families. J Invest Dermatol. 2006;126(3):660–6. Scholar
  21. 21.
    Goldstein AM, Chan M, Harland M, Hayward NK, Demenais F, Bishop DT, et al. Features associated with germline CDKN2A mutations: a GenoMEL study of melanoma-prone families from three continents. J Med Genet. 2007;44(2):99–106. Scholar
  22. 22.
    Bradford PT, Freedman DM, Goldstein AM, Tucker MA. Increased risk of second primary cancers after a diagnosis of melanoma. Arch Dermatol. 2010;146(3):265–72.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Chen T, Hemminki K, Kharazmi E, Ji J, Sundquist K, Fallah M. Multiple primary (even in situ) melanomas in a patient pose significant risk to family members. Eur J Cancer. 2014;50(15):2659–67. Scholar
  24. 24.
    Whiteman DC, Green AC, Olsen CM. The growing burden of invasive melanoma: projections of incidence rates and numbers of new cases in six susceptible populations through 2031. J Invest Dermatol. 2016;136(6):1161–71. Scholar
  25. 25.
    Youlden DR, Youl PH, Soyer H, Aitken JF, Baade PD. Distribution of subsequent primary invasive melanomas following a first primary invasive or in situ melanoma in Queensland, Australia, 1982–2010. JAMA Dermatol. 2014;150(5):526–34. Scholar
  26. 26.
    Australian Institute of Health and Welfare (AIHW). Melanoma skin cancer. 2017.Google Scholar
  27. 27.
    Australian Institute of Health and Welfare (AIHW). Australian Cancer Incidence and Mortality (ACIM) books: melanoma of the skin. 2017.Google Scholar
  28. 28.
    Cancer Australia. Melanoma of the skin statistics. Australian Government, Strawberry Hills NSW. 2017. Accessed 01 Feb 2017.
  29. 29.
    Youlden DR, Baade PD. The relative risk of second primary cancers in Queensland, Australia: a retrospective cohort study. BMC Cancer. 2011;11(1):1–12. Scholar
  30. 30.
    Bataille V, Bishop J, Sasieni P, Swerdlow A, Pinney E, Griffiths K, et al. Risk of cutaneous melanoma in relation to the numbers, types and sites of naevi: a case-control study. Br J Cancer. 1996;73(12):1605.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Watts CG, Cust AE, Menzies SW, Coates E, Mann GJ, Morton RL. Specialized surveillance for individuals at high risk for melanoma a cost analysis of a high-risk clinic. JAMA Dermatol. 2015;151(2):178–86.CrossRefPubMedGoogle Scholar
  32. 32.
    Leung J, McKenzie S, Martin J, McLaughlin D. Effect of rurality on screening for breast cancer: a systematic review and meta-analysis comparing mammography. Rural Remote Health. 2014;14(2):2730.PubMedGoogle Scholar
  33. 33.
    Australian Institute of Health and Welfare (AIHW). What sort of medical practitioners are there? Workforce: Health work force 2016.Google Scholar
  34. 34.
    Australian Institute of Health and Welfare (AIHW). How many medical practitioners are there? Workforce: Health work force 2016.Google Scholar
  35. 35.
    Welch HG, Woloshin S, Schwartz LM. Skin biopsy rates and incidence of melanoma: population based ecological study. BMJ. 2005;331(7515):481. Scholar
  36. 36.
    Giles G, Staples M, McCredie M, Coates M. Multiple primary melanomas: an analysis of cancer registry data from Victoria and New South Wales. Melanoma Res. 1995;5(6):433–8.CrossRefPubMedGoogle Scholar
  37. 37.
    Hwa C, Price LS, Belitskaya-Levy I, Ma MW, Shapiro RL, Berman RS, et al. Single versus multiple primary melanomas. Cancer. 2012;118(17):4184–92. Scholar
  38. 38.
    Moore MM, Geller AC, Warton EM, Schwalbe J, Asgari MM. Multiple primary melanomas among 16,570 patients with melanoma diagnosed at Kaiser Permanente Northern California, 1996 to 2011. J Am Acad Dermatol. 2015;73(4):630–6. Scholar
  39. 39.
    Pannucci CJ, Wilkins EG. Identifying and avoiding bias in research. Plast Reconstr Surg. 2010;126(2):619–25. Scholar
  40. 40.
    Baade PD, Youl PH, Janda M, Whiteman DC, Del Mar CB, Aitken JF. Factors associated with the number of lesions excised for each skin cancer: a study of primary care physicians in Queensland, Australia. Arch Dermatol. 2008;144(11):1468–76.CrossRefPubMedGoogle Scholar
  41. 41.
    Esserman LJ, Thompson IM, Reid B, Nelson P, Ransohoff DF, Welch HG, et al. Addressing overdiagnosis and overtreatment in cancer: a prescription for change. Lancet Oncol. 2014;15(6):e234–42. Scholar
  42. 42.
    Wernli KJ, Henrikson NB, Morrison CC, Nguyen M, Pocobelli G, Blasi PR. Screening for skin cancer in adults: updated evidence report and systematic review for the us preventive services task force. JAMA. 2016;316(4):436–47. Scholar
  43. 43.
    Kasparian NA, McLoone JK, Butow PN. Psychological responses and coping strategies among patients with malignant melanoma: a systematic review of the literature. Arch Dermatol. 2009;145(12):1415–27.CrossRefPubMedGoogle Scholar
  44. 44.
    McLoone JK, Watts KJ, Menzies SW, Barlow-Stewart K, Mann GJ, Kasparian NA. Melanoma survivors at high risk of developing new primary disease: a qualitative examination of the factors that contribute to patient satisfaction with clinical care. Psychooncology. 2013;22(9):1994–2000.CrossRefPubMedGoogle Scholar
  45. 45.
    Elliott TM, Whiteman DC, Olsen CM, Gordon LG. Estimated healthcare costs of melanoma in Australia over 3 years post-diagnosis. Appl Health Econ Health Policy. 2017. Scholar
  46. 46.
    Sullivan R, Peppercorn J, Sikora K, Zalcberg J, Meropol NJ, Amir E, et al. Delivering affordable cancer care in high-income countries. Lancet Oncol. 2011;12(10):933–80. Scholar
  47. 47.
    Vuong K, McGeechan K, Armstrong BK, Cust AE. Risk prediction models for incident primary cutaneous melanoma: a systematic review. JAMA Dermatol. 2014;150(4):434–44. Scholar
  48. 48.
    Jacofsky DJ, Haas DA. A payment model that prevents unnecessary medical treatment. Harvard Business Review. 2016. Accessed 27 Apr 2017.

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Caroline G. Watts
    • 1
    • 2
  • Sally Wortley
    • 1
    • 3
  • Sarah Norris
    • 3
  • Scott W. Menzies
    • 4
    • 5
  • Pascale Guitera
    • 2
    • 4
  • Lisa Askie
    • 6
  • Graham J. Mann
    • 2
    • 7
  • Rachael L. Morton
    • 2
    • 6
  • Anne E. Cust
    • 1
    • 2
  1. 1.Sydney School of Public HealthThe University of SydneyCamperdownAustralia
  2. 2.Melanoma Institute Australia, The University of SydneyNorth SydneyAustralia
  3. 3.Menzies Centre for Health Policy, The University of SydneySydneyAustralia
  4. 4.Sydney Melanoma Diagnostic Centre, Sydney Cancer Centre, Royal Prince Alfred HospitalCamperdownAustralia
  5. 5.Dermatology DepartmentRoyal Prince Alfred Hospital, The University of SydneySydneyAustralia
  6. 6.NHMRC Clinical Trials CentreThe University of SydneySydneyAustralia
  7. 7.Centre for Cancer ResearchWestmead Institute for Medical Research, The University of SydneyWestmeadAustralia

Personalised recommendations