Management of basal cell carcinoma in the United States: Can we simplify care and reduce cost?

Abstract

17 Background: Basal cell carcinoma (BCC) is the most common cancer in the US, affecting more than 3 million people every year, and the incidence of BCC is increasing. Traditional management of BCC involves multiple physician visits and a pre-treatment biopsy which may be unnecessary. We assessed the costs of treating BCC, comparing traditional management with a simplified scheme. Methods: We developed a decision analytic model to compare the costs of traditional BCC management with a simplified Detect and Treat (DAT) scheme that eliminates pre-treatment biopsy. We assumed that all patients had an unequivocal BCC diagnosis based on clinical and dermoscopic findings. In the traditional approach, all patients had a biopsy prior to treatment. In the DAT scheme, well delineated lesions ≤1cm in diameter on the trunk and extremities were treated with shave removal and Mohs indicated lesions were referred to Mohs for on-site histologic check, both eliminating pre-treatment biopsy. Distributions of lesion location, size and treatment modality, and estimates of clinical diagnostic accuracy and success of shave removal were from the literature and from an analysis of 240 consecutive BCC cases seen over 5 years at our institution. Costs were based on assumptions about the number of dermatologist visits, tests and procedures required for each strategy, and unit prices from the 2014 Medicare physician fee schedule. Results: The average cost per case in the DAT scheme was $449 for non-Mohs-indicated lesions and $819 for Mohs-indicated lesions, compared with $566 and $864, respectively, with traditional management. DAT was associated with a savings of $117 (21% of total average cost) per non-Mohs-indicated case and $45 (5% of total average cost) per Mohs-indicated case. The combined weighted average savings per case was $95 (15% of total average cost). The magnitude of savings varied with changes in model parameters, but conclusions were similar under a wide range of plausible scenarios. Conclusions: A simplified management strategy that avoids routine pre-treatment biopsy can reduce the cost of treating BCC without compromising quality of care.