M. E. Jodidio1, V. Prasath2, R. Chokshi1, R. A. Schwartz3, R. Chokshi1 1New Jersey Medical School, Surgical Oncology, Newark, NJ, USA 2Ohio State University, Internal Medicine, Columbus, OH, USA 3New Jersey Medical School, Dermatology, Newark, NJ, USA
Introduction: Basal cell carcinoma (BCC), the most common form of carcinoma, accounts for more than 3.6 million new cases in the United States annually. BCCs rarely metastasize and are usually curable if treated early. Currently accepted treatments for BCC include standard surgical excision and Mohs micrographic surgery (Mohs). Our decision analysis aimed to compare costs and quality-of-life associated with short-term outcomes in treating BCC with Mohs and SSE to identify the most cost-effective option.
Methods: We designed a decision tree model to understand the costs and benefits of the standard surgical management modalities for basal cell carcinoma skin cancers in the United States: Mohs and SSE. The tree describes costs and treatment strategies to incorporate potential skin cancer recurrence over five years. We determined costs from the 2023 Medicare reimbursement rates using a third-party payer perspective for physicians. The effectiveness of treatment strategies was represented using quality-adjusted life years (QALYs). One QALY equals one year of perfect health, while zero QALYs equals death. One-way, two-way, and probabilistic sensitivity analyses were utilized to test the strength of our results.
Results: SSE was the most cost-effective treatment modality for BCC over Mohs with a cost of $1447.02 with 4.978 QALYs. Mohs had a cost of $2547.42 with 4.979 QALYs. Across 100,000 Monte-Carlo simulations, 100% of trials favored SSE. Finally, one-way and two-way sensitivity analyses did not identify any situations where Mohs was preferred over SSE.
Conclusion: In our simulated patients with diagnosed BCC, the most cost-effective treatment strategy was SSE. Both Mohs and SSE have similar impacts on QALY, with Mohs being the more expensive treatment. However, our study did not look at the impact of these procedures on cosmetics, mental impact, and function. It is possible that Mohs should be the treatment chosen for BCCs in anatomical areas where skin preservation is a priority. Quality of life metrics, such as QALY, should consider the impacts of scarring, emotional distress, and other factors currently not considered, as they may impact these types of analyses.