Long Term Cost Comparisons of Radical Cystectomy versus Trimodal Therapy for Muscle-Invasive Bladder Cancer

Bladder cancer is the most costly cancer with prior estimates not accounting for the development of newer agents. Radical cystectomy (RC) and trimodal therapy (TMT) combining maximal transurethral resection of bladder tumor (TURBT) with chemoradiation are the guideline recommended treatment options for nonmetastatic MIBC. The increased adoption of TMT aligns with a desire among patients for bladder sparing options with improved quality of life. However, there remains debate regarding the oncologic benefit of TMT versus RC as clinical trial evidence remains absent. As bladder cancer treatment costs continue to rise it is critical to compare treatment costs. We sought to determine long-term costs of care by comparing the 2- and 5-year costs associated with TMT versus RC and also costs for patients who received no curative treatment. This extends our prior work where costs were aggregated to only 1 year.

Using the Surveillance, Epidemiology, and End Results (SEER)-linked Medicare database we identified a total of 2,537 patients with MIBC from January 1, 2002, through December 31, 2009. Medicare expenditures were summed from inpatient, outpatient (including neoadjuvant chemotherapy), and physician services within 2 and 5 years of diagnosis to determine total costs. Given the heterogeneity in patient populations, inverse probability of treatment-weighted (IPTW) propensity score models adjusted for differences in baseline characteristics between the two treatment modalities. After logistic regression modeling and adjustments using IPTW propensity score models, we found that TMT sustained higher costs at 2-years ($372,839 vs $191,363; Median Difference $127,815, Hodges-Lehmann Estimate (H-L) 95% Confidence Interval (CI), $112,663 to $142,966) and 5-years ($424,570 vs. $253,651; Median Difference $124,466, H-L 95% CI, $105,711 to $143,221) after diagnosis compared to RC. This cost differential was largely driven by associated outpatient expenditures (i.e medications and radiology services). Interestingly, during the initial 2-year time horizon TMT was substantially more expensive, however, the cost differences decreased up to 5 years ($51,721 for TMT vs. $62,288 for RC) with treatment costs becoming relatively comparable. An additional novel finding is that we quantified long-term costs for patients with localized MIBC who received no treatment. These long terms costs at 5-years were not insignificant totaling ~$88,000 and the median survival among these patients was 9 months (IQR 3.2-36.1).

Earlier studies on the cost of muscle-invasive bladder cancer treatments are limited to short-term costs of care. This study provides a potential benchmark by comparing the long-term costs of care beyond 1-year to inform current and future decision-making regarding approval and value of newer agents for localized MIBC. Further, prior studies have not benchmarked costs for bladder cancer patients who received no treatment and could potentially help providers have a more robust discussion about the financial toxicity associated with bladder cancer care. In summary, these long-term cost findings have important health policy implications regarding granular cost drivers for clinical service lines in facilitating future value based care strategies.

Written by: Vishnukamal Golla, MD, MPH^1,2,3 and Stephen B. Williams MD, MS⁴

Department of Surgery, Division of Urology, Duke University, Durham, NC, USA
Section of Urology, Durham VA Medical Center, Durham, NC, USA
Duke National Clinician Scholars Program, Durham, NC, USA
Department of Surgery, Division of Urology, The University of Texas Medical Branch, Galveston, TX, USA

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