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Background: The Affordable Care Act's Medicaid expansion is associated with earlier diagnosis and improved care among lower socioeconomic status populations with cancer, but its impact on melanoma is undefined., Objective: To determine the association of Medicaid expansion with stage of diagnosis and use of sentinel lymph node biopsy in nonelderly adult patients with newly diagnosed clinically localized melanoma., Methods: Quasi-experimental, difference-in-differences retrospective cohort analysis using data from the National Cancer Database from 2010 to 2017. Patients from expansion versus nonexpansion states and diagnosed before (2010-2013) versus after (2014-2017) expansion were identified., Results: Of 83,322 patients, 46.6% were female, and the median age was 55 years (interquartile range, 49-60). After risk adjustment, Medicaid expansion was associated with a decrease in the diagnosis of T1b stage or higher melanoma (odds ratio [OR], 0.93; 95% confidence interval [CI], 0.88-0.98; P = .011) and decrease in uninsured status (OR, 0.61; 95% CI, 0.52-0.72; P < .001) but was not associated with a difference in sentinel lymph node biopsy performance when indicated (OR, 1.06; 95% CI, 0.95-1.20; P = .29)., Limitations: Retrospective study using a national database., Conclusion: In this study of patients with clinically localized melanoma, Medicaid expansion was associated with a decrease in the diagnosis of later T-stage tumors., Competing Interests: Conflicts of interest None disclosed., (Copyright © 2021 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Introduction: National Comprehensive Cancer Network guidelines recommend that sentinel lymph node biopsy (SLNB) be discussed with patients with thin melanoma at higher risk for lymph node metastasis (T1b or T1a with positive deep margins, lymphovascular invasion, or high mitotic index). We examined the association between SLNB and resource utilization in this cohort., Methods: We conducted a retrospective cohort study of patients that underwent wide local excision for higher risk thin melanomas from 2009 to 2018 at a tertiary care center. Patients who underwent SLNB were compared to those who did not undergo SLNB with regard to resource utilization, including total hospital cost., Results: A total of 70 patients were included in the analysis and 50 patients (71.4%) underwent SLNB. SLNB was associated with increased hospital costs ($6700 vs. $3767; p < .01) and increased operative time (68.5 vs. 36.0 min; p < .01). This cost difference persisted in multivariable regression (p < .01). Of patients who underwent successful SLN mapping, 3 out of 49 patients had a positive SLN (6.1%). The cost to identify a single positive sentinel lymph node (SLN) was $47,906., Conclusion: In patients with a higher risk of thin melanoma, SLNB is associated with increased cost despite a low likelihood of SLN positivity. These data better inform patient-provider discussions as the role of SLNB in thin melanoma evolves., (© 2020 Wiley Periodicals LLC.)

Background: Sentinel lymph node biopsy (SLNB) has shown promise in identifying subclinical nodal metastasis in patients with high-risk cutaneous squamous cell carcinoma. However, low metastasis rates may indicate that performing such a procedure in all patients may be unnecessary and costly., Materials and Methods: A decision model was developed to analyze costs and survival in patients with head and neck cutaneous squamous cell carcinoma based on their tumor and nodal metastasis staging and whether or not they received an SLNB. Incremental cost-effectiveness ratios were calculated based on the change in quality-adjusted life years (QALYs) and costs (US$) between the different options, with a threshold of $100,000 to determine the most cost-effective strategy. One-way, two-way, and probabilistic sensitivity analyses were performed to validate the results., Results: Not performing an SLNB results in 12.26 QALYs and a cost of $3712.98. Performing an SLNB resulted in a 0.59 decrease in QALYs and an increase in cost of $1379.58 for an incremental cost-effectiveness ratio of -2338.27. This trend remained the same across all tumor stages and remained consistent within most sensitivity analyses., Conclusions: In patients with head and neck cutaneous squamous cell carcinoma, the most cost-effective strategy is to not perform SLNBs, regardless of the patient's stage. Low rates of nodal metastasis in addition to low disease-specific death rates were the significant factors in this outcome. Increasing the sensitivity of SLNB would not impact this recommendation unless the rate of nodal metastasis was significantly higher., (Copyright © 2019 Elsevier Inc. All rights reserved.)

The Multicenter Selective Lymphadenectomy Trials indicate that there are no overall or melanoma-specific survival advantages to performing sentinel lymph node biopsy (SLNB) followed by immediate completion lymph node dissection compared with wide excision and observation for patients with positive sentinel nodes. These results make SLNB solely a staging procedure. The role of SLNB in the management of patients with melanoma deserves reappraisal. The potential marginal benefit of SLNB beyond the clinical and pathologic features of the melanoma has not been well studied. The use of sentinel lymph node status alone to accept and stratify patients into trials or to receive adjuvant treatment is not rational., (Copyright © 2018 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Background and Objectives: Locoregional lymph node ultrasound is not typically included in guidelines as part of the staging process prior to sentinel lymph node biopsy (SLNB). The objective of the present study was to make a clinical and economic analysis of lymph node ultrasound prior to SLNB., Materials and Methods: We performed a retrospective study of 384 patients with clinical stage I-II primary melanoma who underwent locorregional lymph node ultrasound (with or without ultrasound-guided biopsy) prior to SLNB between 2004 and 2015. We evaluated the reliability and cost-effectiveness of the strategy., Results: Use of locorregional lymph node ultrasound avoided SLNB in 23 patients (6%). Ultrasound had a sensitivity of 46% and specificity of 76% for the detection of metastatic lymph nodes that were not clinically palpable. False negatives were significantly more common in patients aged over 60 years and in tumors with a thickness of less than 2mm. The staging process using SLNB and ultrasound with ultrasound-guided biopsy produced an increase of €16.30 in the unit price. Our cost-effectiveness analysis identified the staging protocol with ultrasound and SLNB as the dominant strategy, with a lower cost-effectiveness ratio than the alternative, consisting of SLNB alone (8,095.24 vs. €28,605.00)., Conclusions: Ultrasound with ultrasound-guided biopsy for the diagnostic staging of melanoma prior to SLNB is a useful and cost-effective tool. This procedure does not substitute SLNB, though it does allow to avoid SLNB in a not insignificant proportion of patients., (Copyright © 2017 AEDV. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background: Sentinel node biopsy (SNB) is commonly performed in contemporary melanoma management, however there is a paucity of long-term quality of life (QoL) estimates required for economic evaluation of this treatment., Methods: A single-center, prospective, cross-sectional study of adults with American Joint Committee on Cancer stage I/II/IIIA melanoma of the limbs, trunk, or neck who had undergone wide excision and SNB, but not complete regional node dissection, was undertaken. Limb volume was measured using perometry, with lymphedema defined as a ≥10% volume increase in the ipsilateral limb compared with the contralateral limb. The Functional Assessment of Cancer Therapy-Breast (FACT-B) questionnaire measured QoL. Associations between patient and treatment characteristics were assessed using linear regression., Results: Among 694 patients (median time from SNB of 37 months), 14 (2%) had objectively measured lymphedema (i.e. an increase in limb volume of ≥10%). Of 687 stage I/II patients with complete QoL data, the mean weighted QoL was 0.745 (standard deviation 0.04) on a 0-1 scale (i.e. death to full health). In multivariable analysis, weighted QoL was 0.0004 higher for each year of increasing age (p = 0.001); 0.011 lower for females (p = 0.001), 0.018 lower following post-SNB limb trauma (p = 0.002); 0.252 lower for patients who perceived a large increase in limb size (p = 0.015); and 0.027 lower with self-reported difficulty in walking, running, or climbing stairs (p = 0.043)., Conclusions: Our data suggest that very few patients treated at our institution had lymphedema in the long-term following SNB, with weighted QoL strongly associated with perceived rather than actual changes in limb size.

Objective: To assess the cost-effectiveness of the sentinel node biopsy with lymphadenectomy for nodal metastases (SNB) in patients with primary cutaneous melanoma (CM) of different Breslow thickness (intermediate, thick, thin)., Methods: Decision tree models were constructed to compare two different strategies of management of patients with CM, wide excision of the primary lesion and SNB and wide excision only (WE). Tree models were created for every Breslow thickness over 1-, 5- and 10-year time horizons. Mean and total direct healthcare costs, life years saved (LYSs), quality-adjusted life years (QALYs), cost effectiveness ratio (CER), and incremental cost effectiveness ratio (ICER) were estimated. Every model was considered as a base case, and its results tested with sensitivity analyses., Results: Base case analyses showed that the best results were obtained for intermediate CM over 10-year time horizon. In this case, ICER for SNB was 130,508€/QALY, well over the threshold of acceptance (30,000€/QALY). In patients with intermediate CM over 1 and 5 years, and for those with thick and thin CM at any time horizon, negative ICER values were estimated since SNB was proved to be more expensive and less effective than WE. Sensitivity analyses confirmed the robustness of our results., Conclusions: SNB caused no improvement in health outcomes in terms of LYSs and QALYs in patients with thick and thin CM, and only a slight benefit in those with intermediate CM. WE was more cost-effective compared with SNB for any CM thickness over any time horizon up to 10 years., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background and Objectives: Solitary dermal melanoma (SDM) is melanoma confined to subcutaneous and/or dermal layers in the absence of a known primary cutaneous lesion. We hypothesized that sentinel node biopsy is an effective staging strategy for this rare disease., Methods: A Markov decision model was constructed to represent two management strategies for SDM: wide local excision followed by observation, and wide local excision followed by sentinel node biopsy. Utilities, likelihood of positive sentinel node biopsy, and cancer progression rates during a five year time horizon were assigned based on institutional data and a review of existing literature. Estimated costs were derived using Medicare reimbursements., Results: Excision followed by sentinel node biopsy provides greater utility, yielding 3.85 discounted quality-adjusted life years (dQALY) compared to 3.66 for excision alone. The incremental cost-effectiveness ratio for sentinel node biopsy is $19,102 per dQALY. Sensitivity analyzes demonstrated that observation is more cost-effective if greater than 23% of sentinel node biopsies are positive (16% reported), or if 5-year survival for observed patients is greater than 76% (69% reported)., Conclusions: Based on existing clinical evidence, sentinel node biopsy yields greater utility than excision alone and is cost-effective for patients presenting with solitary dermal melanoma., (© 2015 Wiley Periodicals, Inc.)

Background: Sentinel lymph node excision (SLNE) for the detection of regional nodal metastases and staging of malignant melanoma has resulted in some controversies in international discussions, as it is a cost-intensive surgical intervention with potentially significant morbidity., Objective: The present retrospective study seeks to clarify the effectiveness and reliability of SLNE performed under tumescent local anaesthesia (TLA) and whether SLNE performed under TLA can reduce costs and morbidity. Therefore, our study is a comparison of SLNE performed under TLA and general anaesthesia (GA)., Patients: We retrospectively analysed data from 300 patients with primary malignant melanoma with a Breslow index of ≥1.0 mm., Results: Altogether, 211 (70.3%) patients underwent SLNE under TLA and 89 (29.7%) patients underwent SLNE under GA. A total of 637 sentinel lymph nodes (SLN) were removed. In the TLA group 1.98 SLN/patient and in the GA group 2.46 SLN/patient were removed (median value). Seventy patients (23.3%) had a positive SLN. No major complications occurred. The costs for SLNE were significantly less for the SLNE in a procedures room performed under TLA (mean € 30.64) compared with SLNE in an operating room under GA (mean € 326.14, P<0.0001)., Conclusion: In conclusion, SLNE performed under TLA is safe, reliable, and cost-efficient and could become the new gold standard in sentinel lymph node diagnostic procedures., (© 2010 The Authors. Journal of the European Academy of Dermatology and Venereology © 2010 European Academy of Dermatology and Venereology.)

Unlabelled: Sentinel lymph node biopsy for melanoma was introduced in the early 1990s as a minimally invasive method of identifying and pathologically staging regional lymph node basins in patients with clinical stage I/II melanoma. Numerous large trials have demonstrated that sentinel lymph node evaluation has utility in improving accuracy of prognostication and for risk stratifying patients into appropriate groups for clinical trials. However, there remains a great deal of controversy regarding the therapeutic role of removal of the remainder of locoregional lymph nodes should metastatic cells be identified in the sentinel node. This CME article will outline a brief history of the sentinel node concept before reviewing updates in surgical technique, histopathologic evaluation of nodal tissue, and cost effectiveness of sentinel node biopsy., Learning Objectives: After completing this learning activity, participants should be able to describe the concept of sentinel lymph node biopsy, to discuss the risks and benefits associated with this procedure, and to summarize the role of sentinel lymph node biopsy in management of patients with melanoma., (Copyright 2010 American Academy of Dermatology, Inc. Published by Mosby, Inc. All rights reserved.)

Background: The aim of this study was to determine the cost-effectiveness of wide excision (WEX) + sentinel node biopsy (SNB) compared with WEX only in patients with primary melanomas >/=1 mm in thickness., Methods: A Markov model was populated with probabilities of disease progression and survival from the published literature. Costs were obtained from diagnostic-related group weightings and health outcomes were measured in quality-adjusted life years (QALYs)., Results: Base case analyses suggested that, over a 20-year timeframe, the mean total cost per patient receiving WEX only was AU $23,182 with 10.45 life years (LY) and 9.90 QALYs. The mean cost per patient for WEX + SNB was AU $24,045 with 10.77 LY and 10.34 QALYs. The incremental cost effectiveness ratio for WEX + SNB was AU $2,770 per LY and AU $1,983 per QALY., Conclusion: WEX + SNB appears to offer an improvement in health outcomes (in both LYs and QALYs) with only a slight increase in cost.

Introduction: Many surgeons use the "10% rule" to define whether a lymph node is a sentinel node (SLN) when staging malignant melanoma. However, this increases the number of SLN removed and the time and cost of the procedure. We examined the impact of raising this threshold on the accuracy of the procedure., Methods: We reviewed the records of 561 patients with melanoma (624 basins) who underwent SLN with technetium Tc99 labeled sulfur colloid using a definition of a SLN as 10% of that of the node with the highest counts per minute (CPM)., Results: Of the 624 basins, 154 (25%) were positive for metastases. An average of 1.9 nodes per basin were removed (range 1-6). Metastases were found in the hottest node in 137 cases (89% of positive basins, 97% of basins overall). Increasing the threshold above 10% decreased the number of nodes excised and the costs involved, but incrementally raised the number of false negative cases above baseline (a 4% increase for a "20% rule," 5% for a "30% rule," 6% for a "40% rule," and 7% for a "50% rule"). Taking only the hottest node would raise the false negative rate by 11%., Conclusions: Although using thresholds higher than 10% for the definition of a SLN will minimize the extent of surgery and decrease the costs associated with the procedure, it will compromise the accuracy of the procedure and is not recommended., (Copyright 2007 Wiley-Liss, Inc.)

Background: Consideration of sentinel lymph node biopsy (SLNB) is recommended for thin melanomas with poor prognostic features; however, few metastases are identified. The purpose of this study was to assess the cost effectiveness of SLNB in this population., Methods: The prospective melanoma database was reviewed to identify patients with melanomas <1.2 mm thick who had undergone SLNB. Physician and hospital charges were collected from the appropriate billing department., Results: A total of 138 patients were identified over an 8-year period (1994-2002). Two patients with positive SLNs were identified (1.4%), one with a melanoma <1 mm thick. Patient charges for SLNB ranged from $10,096 to $15,223 US dollars, compared with $1000 to $1740 US dollars for wide excision as an outpatient. Using these charges, the cost to identify a single positive SLN would be between $696,600 and $1,051,100 US dollars. The cost for wide excision would be between $69,000 and $120,100 US dollars. Assuming that all patients with a positive SLN would die of melanoma, the cost per life saved would be $627,000 to $931,000 US dollars., Conclusions: The cost of performing SLNB in this population is great and only a small number will have disease identified that will alter treatment. These data call into question the appropriateness of SLNB for thin melanomas.

Clinical studies have demonstrated that high dose adjuvant interferon therapy improves disease-free and overall survival among high risk (stage IIb and III) melanoma patients. Sentinel lymph node mapping (SLM) has been shown to accurately detect micrometastasis and may be used to identify higher risk stage II patients, who might benefit most from adjuvant interferon therapy. We modelled the cost-effectiveness of first testing with SLM and then treating with adjuvant interferon (IFN) therapy for stage II melanoma. We used a decision analytical model to compare four strategies for stage II patients after surgical excision of their melanoma: (1) treat all with low dose IFN; (2) test first with SLM and then treat only those with positive micrometastasis with high dose IFN; (3) test first with SLM and treat positives with high dose IFN and negatives with low dose IFN (test and treat appropriately); and (4) surgery only. Treatment, toxicity, follow-up and relapse costs were included over a 5 year time period. The primary outcome was cost per quality-adjusted relapse-free life year saved. Our analysis shows that, compared with the current surgery-only strategy, all three treatment strategies provide incremental benefits. The test and treat appropriately strategy is the most effective, with an incremental improvement of 0.64 quality-adjusted life-years (QALY). The cost-effectiveness of test and treat some with high dose IFN compared with the surgery-only strategy is $18,700/QALY. The test and treat appropriately strategy is also cost-effective compared with test and treat some at $31,100/QALY. In conclusion appropriate dosing of IFN therapy based on the results of SLM is a cost-effective strategy for stage II melanoma patients.

A consecutive cohort of 100 patients who had undergone sentinel lymph node biopsy (SLNB) was analysed retrospectively. Three areas were studied: success in finding the sentinel node(s); complications of the procedure; and extra costs incurred by SLNB. The sentinel node(s) were successfully identified in 98% of the lymph node basins biopsied. The overall complication rate was 33%. The additional cost of the procedure was estimated at 1420 pounds sterling per patient. SLNB can reliably identify the sentinel node. However there is a significant complication rate of the technique and considerable additional costs. SLNB requires further critical evaluation before it can be accepted as a standard treatment for patients with malignant melanoma., (Copyright 2000 The British Association of Plastic Surgeons.)