Adoracion Nieto-Garcia

Economic evaluation of a store-and-forward teledermatology system for skin cancer patients:

We conducted an economic analysis of a store-and-forward teledermatology system for the routine triage of skin cancer patients. A cost-identification, cost-effectiveness and sensitivity analysis under a societal perspective was used to compare teledermatology with the conventional care alternative. In the period March 2004 to July 2005, a total of 2009 teledermatology referrals were managed from 12 Primary Care Centres (PCCs) of the public health system. The unit cost was of €79.78 per patient in teledermatology, and €129.37 per patient in conventional care (P < 0.005), with an incremental cost of €49.59 per patient in favour of teledermatology. The cost ratio between teledermatology and conventional care was 1.6. There was a significant inverse relation between the unit cost in each participating PCC and the number of teleconsultations transmitted from them (P < 0.001). Teledermatology resulted in a more cost-effective, or dominant, methodology. In a public health system equipped with an intranet, the routine use of teledermatology in skin cancer clinics is a cost-effective method of managing referrals.

Isolated Limb Perfusion for Malignant Melanoma: Systematic Review on Effectiveness and Safety

BACKGROUND Isolated limb perfusion (ILP) involves the administration of chemotherapy drugs directly into a limb involved by locoregional metastases. Unresectable locally advanced melanoma of the limbs represents one of the clinical settings in which ILP has demonstrated benefits. METHODS A systematic review of the literature on ILP for patients with unresectable locally advanced melanoma of the limbs was conducted. MEDLINE, EMBASE, and Cochrane database searches were conducted to identify studies fulfilling the following inclusion criteria: hyper- or normothermic ILP with melphalan with or without tumor necrosis factor (TNF) or other drugs providing valid data on clinical response, survival, or toxicity. To allocate levels of evidence and grades of recommendation the Scottish Intercollegiate Guidelines Network system was used. RESULTS Twenty-two studies including 2,018 ILPs were selected with a clear predominance of observational studies (90.90%) against experimental studies (9.10%). The median complete response rate to ILP was of 58.20%, with a median overall response rate of 90.35%. ILP with melphalan yielded a median complete response rate of 46.50%, against a 68.90% median complete response rate for melphalan plus TNF ILP. The median 5-year overall-survival rate was 36.50%, with a median overall survival interval of 36.70 months. The Wieberdink IV and V regional toxicity rates were 2.00% and 0.65%, respectively. CONCLUSIONS ILP is effective in achieving clinical responses in patients with unresectable locally advanced melanoma of the limbs. The disease-free and overall survival rates provided by ILP are acceptable. ILP is safe, with a low incidence of severe regional and systemic toxicity.

New insights into the role of the immune microenvironment in breast carcinoma

Recently, immune edition has been recognized as a new hallmark of cancer. In this respect, some clinical trials in breast cancer have reported imppressive outcomes related to laboratory immune findings, especially in the neoadjuvant and metastatic setting. Infiltration by tumor infiltrating lymphocytes (TIL) and their subtypes, tumor-associated macrophages (TAM) and myeloid-derived suppressive cells (MDSC) seem bona fide prognostic and even predictive biomarkers, that will eventually be incorporated into diagnostic and therapeutic algorithms of breast cancer. In addition, the complex interaction of costimulatory and coinhibitory molecules on the immune synapse and the different signals that they may exert represent another exciting field to explore. In this review we try to summarize and elucidate these new concepts and knowledge from a translational perspective focusing on breast cancer, paying special attention to those aspects that might have more significance in clinical practice and could be useful to design successful therapeutic strategies in the future.

An Economic Analysis of Presurgical Teledermatology in Patients with Nonmelanoma Skin Cancer

INTRODUCTION In patients with nonmelanoma skin cancer, store-and-forward teledermatology allows satisfactory diagnosis and surgical planning, thus shortening waiting lists and reducing travel requirements for patients in special situations. OBJECTIVE The aim of this study was to undertake an economic analysis of presurgical teledermatology, comparing it with a conventional health care approach. MATERIAL AND METHODS The cost and cost-effectiveness of presurgical teledermatology were analyzed from a societal perspective in the setting of a public hospital with a corporate intranet. The mean delay in surgery was used to measure effectiveness. Over a 12-month period, teledermatology was used in 134 patients with nonmelanoma skin cancer. The unit cost of each intervention (teledermatology and conventional health care approach), the cost ratio between the most and least expensive alternative, and the incremental cost-effectiveness ratio were calculated. We distinguished between 2 groups of patients: those with and those without physical impediments for travel. RESULTS The unit cost of the patients in whom teledermatology was used was euro 156.40 compared to euro 278.42 per patient in the conventional system; the conventional system was therefore 1.78 times more expensive than presurgical teledermatology. Teledermatology was more cost-effective, with an incremental cost-effectiveness ratio of euro 3.10 per patient and per day of delay avoided in patients without impediments for travel and euro 4.87 in those with impediments for travel. CONCLUSION Teledermatology used for remote presurgical planning and preparation in patients with nonmelanoma skin cancer is more cost-effective than the conventional referral system in a health setting with a communication network available.

Teledermatología prequirúrgica en pacientes con cáncer cutáneo no melanoma. Evaluación económica

Resumen Introduccion En pacientes con cancer de piel no melanoma la teledermatologia diferida permite una adecuada aproximacion diagnostica y planificacion quirurgica, acortando la demora y evitando desplazamientos en pacientes con situaciones especiales. Objetivo Evaluacion economica de la teledermatologia prequirurgica, comparandola con la asistencia convencional. Material y metodo Descripcion de costes y analisis coste-efectividad bajo una perspectiva social de la teledermatologia prequirurgica en el ambito de un hospital publico dotado de infraestructura de redes (intranet corporativa). Se considero como medida de efectividad la demora media hasta la intervencion quirurgica. Durante un periodo de 12 meses se atendieron un total de 134 pacientes con cancer no melanoma mediante teledermatologia, calculando el coste unitario de cada intervencion (teledermatologia y asistencia convencional), la ratio de coste entre la alternativa mas cara y la mas barata y la ratio de coste-efectividad incremental. Se diferenciaron dos grupos de pacientes, con y sin dificultades fisicas para el desplazamiento. Resultados El coste unitario de los pacientes atendidos mediante teledermatologia fue de 156,40 euros, frente a 278,42 euros por paciente en el sistema convencional; la asistencia convencional resulto 1,78 veces mas cara que la teledermatologia prequirurgica. La teledermatologia demostro ser mas coste-efectiva, con una ratio coste-efectividad incremental de 3,10 euros ahorrados por paciente y dia de demora evitado en pacientes sin dificultades para el desplazamiento, y de 4,87 euros en pacientes con dificultades para el desplazamiento. Conclusion La teledermatologia orientada a la planificacion y preparacion prequirurgica remota de pacientes con cancer no melanoma es una intervencion mas coste-efectiva que el sistema de derivacion convencional en un medio sanitario dotado de infraestructura de redes de comunicacion.

Role of Age and Sex in the Diagnosis of Early-stage Malignant Melanoma: A Cross-sectional Study

Age and sex have been identified as predictors of outcome in malignant melanoma (MM). This aim of this multicentre, cross-sectional study was to analyse the role of age and sex as explanatory variables for the diagnosis of thin MM. A total of 2430 patients with MM were recruited. Cases of in situ-T1 MM were more frequent than T2-T4 MM (56.26% vs. 43.74%). Breslow thickness increased throughout decades of life (analysis of variance (ANOVA) p < 0.001), with a weak correlation between Breslow thickness and patients age (r   = 0.202, p < 0.001). Breslow thickness was significantly less in women (1.79 vs. 2.38 mm, p = 0.0001). Binary logistic regression showed a significant (p < 0.001) odds ratio for age 0-29 years (1.18), and 30-59 years (1.16), and for women (1.09). Age and sex explained 3.64% of the variation observed in Tis-T1 frequency (R2 = 0.0364). Age and sex appear to explain a low percentage of the variation in the early detection of MM.

Association between tumor size and Breslow's thickness in malignant melanoma: a cross-sectional, multicenter study.

The aim of this study was to assess the potential role of tumor diameter in explaining variations in tumoral invasion and in the initial prognosis for patients with malignant melanoma (MM). This was a multicenter, cross-sectional study that recruited between 2000 and 2009 patients with primary in-situ MM (Tis) and invasive cutaneous MM. Tis and MMs with a Breslow’s thickness less than 1 mm (T1) were grouped (Tis–T1) and tumors with a Breslow’s thickness 1 mm or more were also analyzed in combination (T2–T4). The tumor size was measured after routine formalin tissue fixation. Primary outcomes were the correlation between Breslow’s thickness and tumor size, and the role of tumor size in explaining variations in Breslow’s thickness, as assessed by the Pearson correlation test and logistic binary regression with calculation of the odds ratios. A total of 1610 MM patients were included and analyzed. The Pearson correlation between tumor size and Breslow’s thickness was 0.42, with a determination coefficient of R2=0.18 (P>0.01). Correlations between tumor size and thickness were stronger in patients aged 30–60 years (r=0.42, R2=0.1764, P<0.001) and in tumors arising on the upper limbs (r=0.55, R2=0.3025). The odds ratio of identifying a T2–T4 stage MM in patients with tumors larger than 1 cm in size was 2.76 (95% confidence interval 2.25–3.39, P<0.001). Even though a direct, positive, and strong association between tumoral size and Breslow’s thickness might be expected in melanoma cases, the strength of this association has been moderate. Tumor size explains a low burden of the variation observed in the Breslow’s thickness.

Second nonmelanoma skin cancer in Spain: frequency and chronology.

Follow‐up of patients with nonmelanoma skin cancer (NMSC) is mainly aimed at the early diagnosis of local recurrences and early detection of a subsequent or second NMSC (sNMSC). However, the frequency and chronology of sNMSC have not been widely studied in the literature.