Prevention versus early detection for long-term control of melanoma and keratinocyte carcinomas: a cost-effectiveness modelling written report

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  1. http://orcid.org/0000-0002-3159-4249Louisa Gordoni,2,iii,
  2. http://orcid.org/0000-0003-4483-1888Catherine Olsen4,
  3. David C Whitemaniii,4,
  4. Thomas M Elliott1,
  5. Monika Janda5,half dozen,
  6. Adele Green1,7
  1. i Section of Population Health, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
  2. two School of Nursing, Queensland University of Applied science, Brisbane, Queensland, Australia
  3. 3 School of Public Health, University of Queensland, Brisbane, Queensland, Australia
  4. four Cancer Control Grouping, Department of Population Health, QIMR Berghofer Medical Research Institute, Herston, Queensland, Commonwealth of australia
  5. 5 Centre of Wellness Services Research, Kinesthesia of Medicine, University of Queensland, Brisbane, Queensland, Australia
  6. half dozen Schoolhouse of Public Health and Social Work, Found for Health and Biomedical Innovation, Queensland Academy of Technology, Brisbane, Queensland, Commonwealth of australia
  7. 7 CRUK Manchester Institute and Kinesthesia of Biology Medicine and Wellness, The University of Manchester, Manchester, United kingdom of great britain and northern ireland
  1. Correspondence to Dr Louisa Gordon; Louisa.Gordon{at}qimrberghofer.edu.au

Abstract

Objective To compare the long-term economic affect of melanoma prevention by sunday protection, with the corresponding impact of early on detection of melanoma to subtract melanoma deaths.

Pattern Toll-effectiveness analysis using Markov cohort model. Data were primarily from two population-based randomised controlled trials, epidemiological and costing reports, and included flow-on effects for keratinocyte cancers (previously non-melanoma skin cancers) and actinic keratoses.

Setting Queensland, Australia.

Participants Men and women with a mean historic period 50 years modelled for 30 years.

Interventions Daily sunscreen employ (prevention) compared with annual clinical skin examinations (early detection) and comparing these in turn with the status quo.

Primary and secondary outcomes Costs, counts of melanoma, melanoma deaths, keratinocyte cancers, life years and quality-adjusted life years.

Results Per 100 000 individuals, for early on detection, primary prevention and without intervention, at that place were 2446, 1364 and 2419 new melanomas, 556, 341 and 567 melanoma deaths, 64 452, 47 682 and 64 659 keratinocyte cancers and £493.v, £386.4 and £406.1 million in economic costs, respectively. In that location were small differences between prevention and early on detection in life years saved (0.09%) and quality-adjusted life years gained (0.x%).

Conclusions Compared with early detection of melanoma, systematic sunscreen use at a population level will forbid substantial numbers of new pare tumours, melanoma deaths and save healthcare costs. Primary prevention through daily apply of sunscreen is a priority for investment in the control of melanoma.

  • melanoma
  • keratinocyte carcinomas
  • early detection
  • master prevention
  • price-effectiveness

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This is an open up access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC Past-NC 4.0) license, which permits others to distribute, remix, conform, build upon this work not-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes fabricated indicated, and the use is not-commercial. See: http://creativecommons.org/licenses/by-nc/iv.0/.

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  • melanoma
  • keratinocyte carcinomas
  • early detection
  • chief prevention
  • toll-effectiveness

Strengths and limitations of this study

  • This is the first report to compare the toll-effectiveness of master prevention and early detection in the context of pare cancer.

  • Melanoma diagnosis and mortality information from the Queensland Cancer Registry are considered as highly accurate and complete.

  • Modelling relied on population outcomes from two randomised controlled trials that serve to minimise bias in key model inputs but indirect comparison analyses were undertaken.

  • Information are deficient for health utilities of multiple keratinocyte carcinomas and benign skin tumours then proxies and minor disutility values for these events were used.

  • Self-reports of peel checks and sunscreen use from the QSKIN study were used and we cannot rule out responder bias.

Introduction

Melanoma is a major public health burden in many fair-skinned populations. It is the nigh serious blazon of skin cancer and can be fatal if diagnosed at advanced stage. Globally, there are around 60 100 deaths each year from melanoma, with one-quarter of these (around 15 500) occurring in the USA, the Britain and Australasia.ane Other skin malignancies such as basal cell carcinoma and squamous jail cell carcinoma (collectively called keratinocyte cancers (KCs)) are the well-nigh common cancers in humans, associated with high costs (US$4.8 billion in the Us in 2011)2 and lowered quality of life though rarely fatal. In add-on, benign pigmented skin lesions such every bit nevi and solar lentigines are very common in blanched individuals while actinic keratoses are common on sun-damaged pare.3 Any evaluation aimed at melanoma command will therefore demand to account for the clinical direction of these additional skin tumours, malignant and benign, that inevitably volition be encountered in the target population.

Ultraviolet (UV) radiation from sunlight or artificial sources is the main ecology crusade of melanoma, KCs and actinic keratoses. Primary prevention activities focus on educating the public to protect their skin from UV radiations using protective clothing and sunscreens, rescheduling outdoor activities and reducing use of indoor tanning devices. Evidence of effectiveness is strongest for sunscreen use.4 5 Improving sun protection behaviours requires upfront financial investment in dominicus prophylactic campaigns and may be hard in some population segments such every bit avid tanners and adolescents. Early on detection of melanoma saves lives past diagnosing and treating tumours early earlier they metastasise. At that place may also exist price benefits in treating small KCs that are detected earlier with treatment past biopsy excision versus more expensive treatment similar Mohs surgery. 2 large population-based studies accept shown that people who had physician skin checks in the 3 years prior to melanoma diagnosis had higher proportions of thin melanomas (≤0.75 mm) than those who had no doc pare checks.6 7 Thickness of melanoma is highly correlated with prognosis8 and so early detection is intuitively appealing and widely supported by dermatologists. Still, early detection programmes deport the risk of overdiagnosis and unnecessary treatments because skin examinations increase the yield (and subsequent handling costs) of indolent skin cancers and benign skin lesions.ix This phenomenon is well documented in screening programmes10 xi where the number of biopsies and excisions of benign pare lesions exceed confirmed peel cancers by fivefold.10 Furthermore, nigh leading health authorities do not endorse population-wide screening for early melanoma detection considering of lack of testify that screening reduces melanoma mortality.12

Estimating the health and economic value of early detection of melanoma on one hand, and melanoma prevention on the other, are critical for determination-making in settings of constrained health budgets, still it appears the 2 strategies have never been compared. We therefore compared the relative toll-effectiveness of programmes of primary prevention of melanoma (through increases in sunscreen use) versus early on detection of melanoma (through whole trunk clinical skin test) with the condition quo, in an Australian population over a 30-year period.

Methods

Study population

Our written report was based on the mainly blanched population of the Australian land of Queensland who experience high UV radiations levels yr-round.

Comparative strategies

Three strategies were compared:

  1. Primary prevention—comprising daily sunscreen utilize.

  2. Early detection—comprising whole-body pare examination by physicians.

  3. No intervention—no dedicated early detection or primary prevention programmes for melanoma or other pare cancers.

The no intervention strategy represents the full general population in Queensland with prevailing levels of sunscreen use and skin examinations (including opportunistic skin checks past family physicians) equally reported from the QSKIN Sunday and Wellness Study13 (see online supplementary figure i). These behaviours are reflected in the costs and outcomes of this modelled strategy. The expected links between strategy and outcomes are illustrated in figure 1. In the absence of long-term skin checking behaviours, we assumed that clinical skin examinations in the early on detection scenario remained constant over time and applied every bit to men and women over 50. Clinical skin examinations were assumed to exist undertaken annually and reverberate prevailing clinical competencies and use of dermoscopy. The incidence of new pare cancers remained elevated in the early detection arm with yearly clinical peel examinations as shown over successive years in a 10-yr customs sample.14 We also assumed that regular sunscreen employ remained constant over fourth dimension, every bit supported past trial bear witness.15 Both the early detection and primary prevention arms correspond 100% of individuals receiving pare examinations or using sunscreen, respectively, although their consequent outcomes are based on pragmatic trial prove where additional background protective behaviours might have occurred.

Supplemental fabric

Trial evidence

For the primary prevention strategy, we used available data from the community-based Nambour Skin Cancer Prevention Trial (n=1621) that evaluated daily awarding of sunday protection gene (SPF) 15+ sunscreen to face, arms and hands versus discretionary utilise of sunscreen for peel cancer prevention. Skin cancer outcomes were monitored past dermatological examinations for the start 5 years and then through record linkage to histopathology reports for fifteen years.four five Trial results showed the effect of daily sunscreen use on incidence of invasive and non-invasive melanomas (HR 0.50, 95% CI 0.24 to 1.02)4 and squamous cell carcinomas (60 minutes 0.65, 95% CI 0.45 to 0.94)5 at 5 years. Routine sunscreen use was sustained in people randomised to the regular application grouping 12 years after the trial ended.15 The principal study limitation is that the results are direct relevant to people living in sunny climates with high ambience lord's day exposure; yet, they volition take implications for white people travelling to sunny places for holidays.4

For the early detection strategy, data from the Skin Awareness Trial16 for men over 50 years were used. This scenario modelled the increase in pare examinations in men and women anile over 50 years. The trial randomised 929 male participants selected randomly from the population-based Balloter Ringlet (enrolment is compulsory) to intervention or control arm.17 The intervention group received comprehensive educational materials almost skin self-examination and the importance of consulting the family doctor for lesions of business organisation.sixteen The control group received an information brochure but. Histopathology reports of skin cancers and benign lesions were obtained at 12 months only.xvi Nosotros estimated long-term survival using population data of melanoma thickness.half dozen Trial results showed increased skin self-examinations in the intervention group (35.3%) versus in the control group (27.two%).16 For lesions that were managed past physicians, there was a college proportion of malignant lesions in the intervention group (60%) versus in the control group40%.16 The key limitation of this study is that men were relatively more than skin aware at baseline (no differences between randomised arms) and non all participants gave permission for the researchers to contact their physicians 321/540 (59.4%).sixteen

Model structure

A Markov wellness country transition cohort model was synthetic in TreeAge Pro for Healthcare 2019 (TreeAge Software, Williamstown, Massachusetts, United states of america) (effigy two). The model prospectively tracked the expected consequences of occurrences and sequelae of new skin lesions. The health states included: (1) melanoma (in situ; 'thin' (≤1 mm thickness); 'thicker' (>i mm); (2) undetected melanoma; (three) KCs; (four) undetected KCs; (5) benign skin lesions; (six) undetected beneficial lesions; (vii) lesion-free and (8) postdiagnosis, thin melanoma; (9) postdiagnosis, thicker melanoma; (10) melanoma deaths and (11) other deaths. Melanomas were categorised into ≤i mm and >1 mm Breslow thickness to enable a parsimonious model construction but weighted values for survival and costs reflect the specific stage differences. The model had annual cycles and the cohort could move between wellness states when they faced different probabilities of developing skin cancers or skin lesions or they could remain in the aforementioned land (eg, lesion-gratis). Some people developed multiple pare cancers and benign lesions and gamble increased with age. Despite the competing risks of different pare cancers, coherence was maintained with probabilities totalling less than ane.0 in the model branches. The model tracked the cohort (mean age 50 years (SD nine)) from inception through the side by side 30 years. Death from melanoma18 including from advanced melanoma,nineteen another pare cancer or other causes20 could occur at any time.

Model inputs and sources

Model inputs and sources are provided in table 1 and the online supplementary file with more detailed information on calculations (eg, weighted means, rate to probability conversions) and groundwork data. Briefly, from the Nambour trial, nosotros estimated the effect of daily sunscreen utilise on incidence of invasive and non-invasive melanomas (HR 0.50, 95% CI 0.24 to ane.02)four and squamous prison cell carcinomas (HR 0.65, 95% CI 0.45 to 0.94)5 (latter used for 'KCs' health state). We estimated long-term survival using population data of melanoma thickness.6 Undetected skin tumours were estimated from a pilot melanoma screening trial in Queensland involving 16 383 skin examinations and showed numbers of suspicious lesions that were histopathologically confirmed equally pare tumours (23% melanoma, 14% KCs and twoscore% benign tumours).21

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Table 1

Model estimates, sensitivity values and sources

Transition probabilities unrelated to interventions. In each annual cycle, a proportion of people will either continue to alive without skin cancer or develop melanoma, KC or other skin lesions. The risks of developing pare cancer increase with historic period. Incidence of KCs was based on the QSKIN written report and observed excisions of at least one KC during 2011–2014 past historic period-group.22 Once treated, individuals can develop subsequent peel cancers, other peel lesions or remain 'lesion-free'. Based on information from the Queensland Cancer Registry from 1995 to 2014,23 the proportions of in situ (45%), thin ≤one mm melanomas (28%%) and thicker >1 mm melanomas (27%) were practical in the model. Probabilities for subsequent multiple skin lesions and tumours were based on Queensland studies.22 24–26 Incidence of multiple invasive melanomas was available from Youlden et al.26 For subsequent melanomas, the thickness distribution (and associated mortality) of melanomas for individuals with multiple melanomas was the aforementioned for singular melanomas.27 Mortality rates for sparse melanomas were extracted from the latest survival data from melanoma from worldwide data (n>46 000).viii Wellness utility scores for melanoma stages, including patients with advanced melanoma receiving targeted therapies, were obtained from a meta-analysis (tabular array one).28 Robust evidence on wellness utilities for patients with KC or beneficial skin lesions is limited, but there is an appreciable quality of life effect where some individuals face disfiguring, multiple cancers, feet and other symptoms.29 From Seidler et al, nosotros assigned a utility score of 0.984 to patients with KCs (0.95 and 0.99 in sensitivity analysis) and a utility reduction of −0.03 each time an individual had an additional KC.thirty

The study took a societal perspective and included wellness provider resource, consumer expenses for sunscreen and copayments for medical treatments and productivity losses to gild for each premature melanoma decease.17 Nosotros included the costs of a primary prevention campaign at AU$0.35 per capita which was conservatively twice that of recent funding for a skin awareness entrada awarded in Western Australia. Healthcare costs included family physician visits for skin checks, specialist visits, pathology and treatments for melanomas, KCs and benign lesions (ie, cryotherapy, excision, topical creams).31 Resources were valued using those reported in the literature or national price schedules, inflated to 2018 Australian dollars and converted into UK pounds (AUD1.444=United states of america$1.0=£0.713 using purchasing power parities).

Analyses

The chief outcomes of interest were counts of melanomas (in situ, thin ≤ane mm and thicker >1 mm), melanoma deaths, KC counts, healthcare costs, survival (life years) and quality-adjusted life years (QALYs). Mean costs, QALYs and all other outcomes for the three strategies were calculated with Monte Carlo simulation analysis and presented per 100 000 persons. Time to come costs and QALYs were discounted at iii% per twelvemonth to provide nowadays values. We calculated incremental toll-effectiveness ratios to compare the strategies: the difference in hateful costs for two strategies divided by the departure in hateful QALYs. Probability distributions for each parameter were assigned using the 95% CIs (if available) or ±15% of the base value (table 1). We conducted 1-way sensitivity analyses in which each model input was varied betwixt loftier and low values (online supplementary figure 2). Scenarios were performed for different durations (10–50 years), starting ages (30–60 years) and removing discounting. Results of the base instance probabilistic sensitivity analysis using Monte Carlo simulation and 5000 iterations at random were presented in an incremental price-effectiveness scatterplot. As a benchmark for price-constructive healthcare in Commonwealth of australia,32 a threshold of AU$50 000 per QALY gained was used. Nosotros validated the model by running internal coherence checks, checked all inputs with ii modellers and assessed predicted outcomes with external reports. All-time-practise guidelines for wellness economic modelling33 34 were adhered to.

Patient and public involvement

The enquiry study did not involve whatever direct patient and public interest.

Results

For the next xxx years where no intervention occurs, information technology was predicted that for every 100 000 persons, 2419 melanomas, 567 melanoma deaths and 64 659 KCs will occur (table ii). Furthermore, ii.half-dozen million life years, 1.viii million QALYs and £406.1 million in economical costs were predicted (table two). This compares with the 30-year outcomes of a primary prevention strategy of 1055 fewer melanomas, 226 fewer melanoma deaths, 16 977 fewer KCs, 1736 additional QALYs and £19.7 million savings in societal costs (table 2). Conversely, for the early detection strategy compared with no intervention, at that place would exist an estimated 21 melanomas (previously undetected), 793 boosted KCs, 6 fewer QALYs and price an additional £87.4 million (table 2). With early detection, diagnosing melanomas that were previously undetected is a positive finding leading to lower-risk cancers simply wellness utility decrements accrue for all melanomas and KCs and the college numbers of early on stage cancers and KCs for resulted in slightly fewer overall QALYs than the no intervention strategy. Main prevention was superior to early detection across most outcomes only at the expense of 21 undetected melanomas per 100 000 and produced pocket-sized differences in life years (0.09%) and QALYs (0.10%) (tabular array two, online supplementary figures iii–5). Compared with primary prevention, early on detection price an additional £107.1 million (22%) to society, and at that place were 531 (47%) more in situ melanomas, 311 (45%) more than thin melanomas and 261 (42%) more thicker melanomas per 100 000 persons (table two).

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Table 2

Projected wellness and economical outcomes over 30 years (mean per 100 000 persons) past strategy

Regarding incremental price per QALY ratios, one-manner sensitivity analyses showed the most of import model inputs were unit cost of skin examinations (range £27.52–£83.78); probability of a melanoma being >i mm (0.21–0.29); rate reduction of benign lesions (0.66–0.86) and wellness utility of KCs (0.95–0.99) (tabular array 3). These variables changed the 'base-instance' incremental cost per QALY ratio for primary prevention versus early detection between −£185 000 and −£31 000 but the overall finding that main prevention incurred lower costs but higher QALYs than early on detection remained unchanged. If the mortality probability of thick melanoma (>1 mm) at 5 years (0.233) and ten years (0.301) was lowered to 0.xix and 0.26, respectively, effect was small-scale and more in favour of primary prevention (4% improvement) (table three).

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Tabular array 3

One-way sensitivity analyses* of model parameters (mean per 100 000 persons) by strategy

When the model duration was shortened to 10 years, or separately increased to 40 years, incremental cost savings (per 100 000) for main prevention versus early detection were £52.9 one thousand thousand and £116.5 million, respectively (tabular array 4). Reducing the starting historic period to 30 years and raising it to threescore years produced price savings of £112.0 million and £93.1 million, respectively, and discounting or not, too produced big differences in costs and QALYs (tabular array four). The probability that chief prevention was cost effective compared with early detection was 100% (online supplementary figures 3-5). Per person hateful incremental cost savings for principal prevention versus early detection were £1071 (95% credible interval: £679 to £1490) and mean QALYs were 0.0174 (95% credible interval: 0.0069 to 0.0365). Model validation indicated high external validity (online supplementary file).

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Table 4

Scenarios* of different structural model parameters (mean per 100 000 persons) past strategy

Give-and-take

In mid-aged people followed up for 30 years, systematic improvements in sunscreen use would prevent peel cancers and benign pare tumours and bring pregnant toll savings. Melanoma deaths afterward thirty years of regular sunscreen use would be 1-third less of that afterward 30 years of increased clinical skin examinations. Every bit expected with an early detection intervention, higher numbers of detected melanomas, KCs and all other skin lesions would be diagnosed and treated than with either the primary prevention or the no intervention scenario. Early detection was favourable in detecting early stage, treatable skin cancers; however, these higher proportions of thin melanomas presenting for medical attending did not commencement the economic and quality of life burdens incurred past concurrently detecting higher numbers of KCs and benign skin lesions. Conversely, main prevention has the dual benefits past fugitive pare cancers altogether and reducing quality of life decrements and costs relative to early detection, although some melanomas would be undetected. With the majority of melanomas routinely detected at early on stages in the general population without dedicated surveillance, there is minimal bear upon on mortality (and therefore life years).

Nosotros compared primary prevention with early on detection and a 'no intervention' baseline group just it is important to stress that the interventions were based on businesslike trials that meant individuals could engage in their normal skin behaviours in Queensland. In earlier iterations of the model, we considered alternative behavioural scenarios just chose the current status quo (or mixed behavioural scenario reflecting existent-life) with culling best possible strategies. Although it may be unrealistic to achieve 100% compliance with protective behaviours, within a pragmatic trial with multiple behaviours possible, the strategies more correctly marshal with the data inputs on outcomes afterwards these behaviours. Behaviours were not explicitly modelled but rather their consequences through rate ratios of skin cancers or thick melanomas and costs. Our use of distributions around the cardinal estimates in the probabilistic sensitivity analyses will implicitly embrace the variations in peel behaviours, costs and health-related quality of life. For case, decrements in quality of life associated with being diagnosed with a skin cancer is probable to exist directly related to both treatment and psychological concerns but varies from person to person.

Eight previous economic evaluations of melanoma early detection programmes have been reported: 3 Australian,35 three US35 and one Belgian36 and United kingdom of great britain and northern ireland.37 All studies used long-term Markov or decision-analytic models as we did, and all showed early detection producing a downshift of melanoma stage and improved survival.35 Several studies included the costs for increased example-finding of KCs and benign tumours but only recent studies recognised the importance of quality of life and used QALYs as a master outcome.36 38 39 Economic evaluations of primary prevention of skin cancer accept varied in intervention type and duration but all have shown favourable economical and health benefits.35

In our ageing populations, mortality from melanoma competes with all-cause bloodshed. At a population level, the deaths of a minor proportion (~five%) of people with melanoma that accept advanced melanoma are somewhat diluted past deaths from other common diseases so the gains in life years from population health strategies are elusive. Instead of population screening, screening those at known high risk of melanoma based, for example, on high numbers of nevi, or fair skin type, has been proposed.39 Developments in imaging technologies may bring improved diagnostic accuracy given that a proportion of difficult-to-diagnose melanomas and KCs40 are liable to misdiagnosis.

We have previously shown that principal prevention via regular sunscreen use reduces economical brunt.41 In England, it is estimated that £180 million will exist spent past the NHS on pare cancer by 2020.42 In the Us, the annual economic brunt of treating melanoma and KCs is US$eight.1 billion, increasing each yr.ii Betwixt 2002–2006 and 2007–2011, growth in costs of melanoma and KCs lonely was fivefold higher than for all other cancers and would be fifty-fifty higher if the full price of treated benign skin tumours were also counted. For example, over 35.6 million actinic keratoses were treated in the US Medicare population in 2015, increasing from 29.seven one thousand thousand in 2007.43 Consequently, the scope for future price savings to health economies through investment in skin cancer campaigns is considerable.35

The generalisability of these findings volition be express to settings resembling this study'due south, although the expected relativities of cost, intervention and quality of life effects should exist proportional to state-specific pare cancer incidence. Some assumptions were necessary in our models, specially regarding melanoma bloodshed rates in the early detection arm, since to date no relevant trials have been adequately powered to detect melanoma deaths. Reports of melanoma mortality after population screening for melanoma in Germany have been mixed.44 A farther effect is the optimal frequency of skin checks since fifty-fifty annual checks may miss apace-growing nodular melanomas at a curable phase. For health utilities of multiple KCs and beneficial peel tumours where information are scarce, we used proxies and small disutility values for these events. Nosotros relied on cocky-reports of skin checks and sunscreen employ from the QSKIN report and cannot dominion out responder bias. Similarly, self-reported skin checks after melanoma diagnosis in a instance control study6 may have been decumbent to call up bias and random misclassification, though the clan between physician skin checks and thinner melanomas has been reported by others.7 Clinical skin examination frequency and outcomes were based on Janda et al 's thirteen-month follow-up information but may vary in practice and therefore produce different numbers of skin malignancies in the early detection arm.16 Although the Nambour trial used SPF15+ sunscreen and our estimates may be conservative compared with sunscreen SPF30+, the furnishings of the very pocket-size deviation in per cent UV filtered past SPF15+ vs 30+ sunscreens45 would have been covered by our sensitivity analyses. Similarly, categorising thin melanomas as <0.8 mm8 rather than ≤1 mm, would not have changed relative differences observed across strategies. Finally, no indirect comparing analysis was undertaken between the randomised trials by Greenish et al 4 and Janda et al.sixteen At baseline, written report participants had similar proportions with fair peel (56% in Green vs 62% in Janda) and sunscreen use (35% in Green vs 33% in Janda). Withal, Green and Janda study participants differed past historic period (included xx–69 year olds vs over l year olds), gender (men 43% vs 100%) and previous history of skin cancers (25% vs 71%), respectively.

These limitations should exist prepare against the major strengths of this piece of work, namely that nosotros used data from ii randomised controlled trials, thus minimising internal bias. We also relied on epidemiological and economic studies in the aforementioned general population, with the same ambience UV radiation levels and the same health organisation. Nosotros used melanoma diagnosis and bloodshed data from the Queensland Cancer Registry that is considered highly accurate and complete.

Decision

Nosotros accept shown that primary prevention through daily use of sunscreen emerges as the priority for investment in the control of melanoma, and secondarily of KC and actinic keratoses in loftier-take a chance populations like Queensland'southward. As a corollary, there would exist no long-term economic benefit in moving to implement whole trunk clinical skin examinations of people aged over l years to reduce the touch on of melanoma. Further enquiry is required to assess relative cost-benefit of early detection of melanoma in high adventure subgroups versus prevention.

Acknowledgments

We gratefully thank Professor Andrew Searles from Hunter Medical Research Establish who reviewed an earlier draft of the manuscript.

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