An estimate of the annual direct cost of treating cutaneous melanoma
Authors: Matthew H. Kanzler
Journal: Journal of the American Academy of Dermatology (1999)

The article by Tsao, Rogers, and Sober showed in an analytical fashion that approximately 90% of the total annual direct cost of treating melanoma in 1997 was attributable to less than 20% of the patients (stage III and stage IV disease) (J Am Acad Dermatol 1998;38:669-80). They conclude that “…aggressive primary prevention through sun protection and intensive screening to enhance earlier detection should reduce the economic burden of melanoma care.” (p 669) This premise is impossible to substantiate, however, because the model they constructed to evaluate costs specifically excluded “the cost of screening.” If, indeed, the cost of an adequate screening program was determined to be exceedingly expensive, then the “economic burden” would increase, not decrease. A few assumptions made in their statistical analysis justify further comment. The authors state, “The Melanoma Center at the Massachusetts General Hospital and other centers around the country routinely obtained a single baseline chest x-ray examination for future comparison…” (p 671) Several recent studies question the usefulness of chest radiography in the initial evaluation of patients with localized melanoma1Terhune MH Swanson N Johnson TM. Use of chest radiography in the initial evaluation of patients with localized melanoma.Arch Dermatol. 1998; 134: 569-572Crossref PubMed Scopus (69) Google Scholar as well as the utility of follow-up radiograms for detection of recurrent disease.2Weiss M Loprinzi CL Creagan ET et al.Utility of follow-up test for detecting recurrent disease in patients with malignant melanoma.JAMA. 1995; 274: 1703-1705Crossref PubMed Scopus (144) Google Scholar In fact, Fader et al3Fader DJ Wise CG Normolle DP et al.The multidisciplinary melanoma clinic: a cost outcomes analysis of specialty care.J Am Acad Dermatol. 1998; 38: 742-751Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar in an article published in the same issue as the current article state that at the University of Michigan Multidisciplinary Melanoma Clinic, “serum chemistries, chest radiographs, or computed tomography scans are not routinely ordered for patients with local disease unless there is clinical suspicion.” (p 750) Scientific data are lacking to support the dogma of routine screening laboratory tests and procedures in patients with melanoma who are otherwise without symptoms. Another controversial issue in the analysis of Tsao et al is stated, “Sentinel lymph biopsy has also become a routine part of stage II disease management.” (p 672) Although this may be true in a research setting such as the Massachusetts General Hospital Melanoma Center, this certainly does not represent the standard of care in the community. In fact, Donald Morton, MD, who pioneered and first reported on this technique in 1992, stated at the Fourth World Congress on Melanoma (1997) in Sidney, Australia, that this procedure cannot be recommended for general clinical practice. He said, “In my opinion, it is inappropriate to use this technique outside a clinical trial setting since therapeutic and prognostic utility remains unproved.” Also at the Fourth World Congress on Melanoma, Alexander Eggermont, MD, PhD, reported that “By the time metastatic disease is present in the lymph nodes, it is most likely that there is also metastatic systemic disease.”4Watson F. Role of adjuvant melanoma surgeries unclear.Dermatol Times. 1997; Oct 19; : 26Google Scholar He stated that selective lymphadenectomy is unlikely to prove therapeutic. Allen C. Halpern, Co-Director of the Pigmented Lesion Group, Department of Dermatology, University of Pennsylvania School of Medicine, stated that, “It is important to emphasize that despite being embraced by many clinicians, SLND [selective lymph node dissection] remains an experimental therapy. It is not proven yet that identifying lymph node disease more effectively saves lives or extends survival period.”5Morton DL Conforti AM. Sentinel lymphadenectomy for clinical stage I melanoma: current status.Melanoma Lett. 1997; 15 (2, 4): 1Google Scholar Finally, in their calculations Tsao et al assumed that these melanoma patients are being charged level 3 CPT follow-up visits. I am going to send Inga Elzay to Massachusetts General Hospital to provide a crash course in Evaluation and Management coding skills! The single most effective method in detecting recurrent melanoma is a comprehensive history and physical examination.2Weiss M Loprinzi CL Creagan ET et al.Utility of follow-up test for detecting recurrent disease in patients with malignant melanoma.JAMA. 1995; 274: 1703-1705Crossref PubMed Scopus (144) Google Scholar, 3Fader DJ Wise CG Normolle DP et al.The multidisciplinary melanoma clinic: a cost outcomes analysis of specialty care.J Am Acad Dermatol. 1998; 38: 742-751Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar, 5Morton DL Conforti AM. Sentinel lymphadenectomy for clinical stage I melanoma: current status.Melanoma Lett. 1997; 15 (2, 4): 1Google Scholar, 6Jillella A Mani S Nair B et al.The role for close follow-up of melanoma patients with AJCC stages I-III: a preliminary analysis.Proc Am Soc Clin Onocol. 1995; 14: 413Google Scholar If a detailed or comprehensive interval history (including an extensive review of systems) is obtained at each follow-up as well as a detailed or comprehensive physical examination, an Evaluation and Management level 4 or 5 visit would be the appropriate visit charge. Down-coding the services to level 3 results in inadequate reimbursement for the work being done in these time-consuming patients.