Economic analysis of first-line treatment for advanced melanoma in a public hospital.

Abstract

e13618 Background: Access to immune checkpoint inhibitors (ICIs) for advanced cutaneous melanoma remains constrained in Brazil’s public health system due to reimbursement limitations. We estimated the direct medical costs of first-line (1L) treatment for advanced cutaneous melanoma at a Brazilian public reference hospital, comparing chemotherapy- and immunotherapy-based strategies. Methods: We conducted a retrospective observational cohort study including patients with advanced cutaneous melanoma treated at the Brazilian National Cancer Institute between January 2020 and December 2023. During this period, chemotherapy with dacarbazine was consistently available, whereas immunotherapy with pembrolizumab became available starting in December 2021. Individual-level resource utilization data were extracted from medical records and institutional databases. Direct medical costs of 1L treatment were estimated from the public healthcare system perspective using a bottom-up microcosting approach. Values were reported in US dollars (USD) with 1 USD = 5.62 Brazilian Reais (reference year 2024). Results: Eighty-seven patients received 1L treatment during the study period: 43 (49%) received dacarbazine and 44 (51%) received pembrolizumab. The total direct medical cost of dacarbazine-based treatment was 311,492.59 USD, corresponding to a mean cost of 7,244.01 USD per patient. In contrast, pembrolizumab-based treatment generated a total cost of 3,364,519.60 USD, with a mean cost of 76,466.35 USD per patient. Cost composition differed markedly between strategies. In the dacarbazine group, hospitalization accounted for 78% of total costs, followed by diagnostic exams and procedures (10%). In the pembrolizumab group, drug acquisition and administration accounted for 90% of total costs, whereas hospitalization represented only 7%. Notably, in absolute terms, hospitalization costs were similar between groups. Costs for exams and supportive care (e.g. transfusion) were approximately doubled in the pembrolizumab group. Conclusions: First-line treatment strategies for advanced cutaneous melanoma exhibit different cost structures within the Brazilian public healthcare system. Chemotherapy-based regimens are associated with lower overall costs, largely driven by hospitalization and supportive care, while immunotherapy-based treatment results in a significantly higher budget impact driven primarily by drug acquisition. Although ICIs are associated with meaningful survival benefits, their affordability remains a major challenge in publicly funded systems. Future analyses incorporating survival, quality-of-life outcomes, and productivity measures are needed to contextualize these costs and inform value-based policy decisions. Strategies such as dosing optimization or interval modification warrant further evaluation to improve sustainability without compromising clinical benefit.