Skelsey MK, Okun MM, Schiro J, Dozier S, Glinert R, Boeri M. Patients' willingness to accept adverse event and cost trade-offs for reduced risk of non-melanoma skin cancer. Presented at the 2022 American Society for Dermatologic Surgery Annual Meeting; October 6, 2022. Aurora, CO.


PURPOSE: Oral nicotinamide supplementation in patients with a history of multiple non-melanoma skin cancers (NMSCs) is associated with a significant 23% annual reduction in rate of new NMSC formation, along with a 100% increase in the relative risk of severe infections (Chen et al., 2015).  It is unknown whether this magnitude of NMSC reduction is valued sufficiently by patients to justify the possibility of side-effects and expense from nicotinamide supplementation.

DESIGN: To quantify the risk for adverse events and magnitude of expense patients are willing to accept for reduction in NMSC incidence, 203 adults with a history of two or more NMSC within the past five years undergoing  Mohs surgery for removal of a NMSC in four clinics in the U.S. were recruited.  Using a discrete-choice experiment, patients completed a series of ten choice questions with three possible answers as options: a pair of hypothetical treatments, and no treatment.  Treatments were characterized by the magnitude of the reduction in incidence of NMSC, the magnitude of the risk of severe infections, and monthly cost.

FINDINGS: For a 23% annual reduction in NMSC incidence, patients were willing to accept a 26% (95% confidence interval:  8-45%) annual increase in risk for severe infection and pay $8 ($2-14) monthly.  A key limitation of the study is that not all potential side effects and benefits associated with nicotinamide supplementation were included in the discrete-choice experiment.

SUMMARY: Patients were not willing to accept risks of severe infection below those observed in a clinical trial of Nicotinamide use, but were willing to accept costs above monthly retail cost, for the relative reductions in NMSC incidence observed in the clinical trial.  Patients with a history of multiple NMSC have a low tolerance for increased risk of severe infections.  As risk of a severe infection is a potential side effect based on the current literature, dermatologists prescribing nicotinamide for chemoprevention should clearly inform patients about the possible risk.  Given the uncertainty of the risk profile, clinicians should be cautious about routinely recommending nicotinamide supplementation to patients with a history of non-melanoma skin cancer.

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