To compare the cost-utility of initial management of high-grade T1 non-muscle invasive bladder cancer (HGT1 NMIBC) with intravesical BCG versus immediate radical cystectomy. High risk NMIBC patients may climb a costly ladder of treatments, culminating in radical cystectomy for oncologic or symptomatic benefit in up to one-third. This high healthcare resource utilization presents a challenging dilemma in balancing sufficiently aggressive management with cost, toxicity, and quality-of-life.
Cost-utility of initially managing HGT1 with intravesical BCG and early radical cystectomy with ileal conduit urinary diversion was compared using decision-analytic Markov models. Five-year oncologic outcomes, adverse event rates, and published utility values were extracted from literature. Costs were calculated from a US Medicare perspective in 2021 US dollars. Sensitivity analysis identified drivers of cost and break-even points for recurrence and progression.
Mean costs were $26,093 for intravesical BCG and $39,720 for immediate radical cystectomy, though cystectomy generated a gain of 2.2 QALYs compared to intravesical BCG. Immediate cystectomy was a more cost-effective management strategy for HGT1 NMIBC with an ICER of $7120/QALY. The costs associated with cystectomy, TURBT, and BCG toxicity had the greatest impact on ICER. One-way sensitivity analysis demonstrated that intravesical BCG became a cost-effective management strategy if the five-year recurrence rate of HG T1 was less than 56% or the five-year progression rate to MIBC was less than 4%.
At current prices, treatment of high-grade T1 NMIBC with early radical cystectomy is more cost-effective management strategy than initial treatment with intravesical BCG.
Urology. 2024 Mar 09 [Epub ahead of print]
Heather L Huelster, Neil T Mason, Facundo Davaro, Syeda Mahrukh Hussain Naqvi, Youngchul Kim, Scott M Gilbert
Department of Genitourinary Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA; Department of Urology, Indiana University Health, Indianapolis, IN 46202, USA. Electronic address: ., Department of Individualized Cancer Medicine, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA., Department of Genitourinary Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA., Department of Biostatistics, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA.