Cost-Effectiveness of Oral Nicotinamide for Keratinocyte Carcinoma Prevention

Keratinocyte carcinoma (KC) is the most common cancer in the US, resulting in considerable clinical and economic burdens. Nicotinamide has been shown to reduce new KCs among high-risk patients. Despite growing clinical interest, the cost-effectiveness of nicotinamide for KC prevention has not been examined.

To evaluate the cost-effectiveness of oral nicotinamide for KC prevention.

This economic evaluation with a 1-year horizon included data from individuals within the Veterans Health Administration (VHA). Individuals with and without nicotinamide exposure for 30 or more days were included. Data were analyzed from September to October 2025.

Oral nicotinamide use compared to no nicotinamide use.

The primary outcome was the annual number of KC events prevented, translated into quality-adjusted life-years (QALYs) gained. Costs included annual nicotinamide expenses and weighted average treatment costs per KC episode. Incremental cost-effectiveness ratios were calculated as the differential cost divided by the differential QALYs gained, supplemented by probabilistic and 1-way sensitivity analyses, non-VHA cost assumptions, and symptom-related quality-of-life modeling.

Among the 33 822 individuals included in the analysis and contributing 78 726 person-years of follow-up, the unexposed cohort had a mean (SD) age of 76.9 (8.7) years, compared with 77.2 (8.9) years in the exposed cohort, and 98.0% were male in both exposure groups. KC incidence was 0.204 per person-year in those exposed to nicotinamide and 0.255 in those who were not exposed, reflecting an absolute risk reduction of 0.051 and 624 annually prevented KCs among 12 287 users. Total nicotinamide cost was $161 451, with $526 032 in treatment cost savings, resulting in a net savings of $364 581. Assuming a 0.01-QALY decrement per KC, nicotinamide use yielded 6.24 QALYs gained per year across the cohort and a differential cost of -$58 426 per QALY gained. At the cohort level, this represented a 19.9% reduction in yearly KC treatment costs. Probabilistic, 1-way, and non-VHA cost analyses resulted in median (IQR; range) and scenario differential costs of -$57 700 (-$79 851 to -$38 836; -$116 853 to -$16 326) and $14 407 per QALY gained, respectively. Prevention of 624 KCs among those exposed to nicotinamide in the cohort preserved more than 8 Skindex-16 symptom points per KC in veterans and civilians.

In this economic evaluation, oral nicotinamide was a cost-effective and patient-centric preventive approach for KC, particularly in individuals with KC history at high risk of multiple primary KC.