By David Douglas
NEW YORK (Reuters Health) - 14/6/2019
In patients with localized muscle-invasive bladder cancer, radical cystectomy appears to have better outcome and may be much less costly than combining radiation, chemotherapy and endoscopic treatments, according to a retrospective study of Medicare data.
As Dr. Stephen B. Williams of The University of Texas Medical Branch at Galveston told Reuters Health by email, "We compared costs up to one year following radical cystectomy versus trimodal therapy and found significantly increased costs associated with trimodal therapy."
Dr. Williams and colleagues examined data on close to 3,000 patients who underwent either treatment between 2002 and 2011; 2,235 had radical cystectomy and 728 underwent trimodal therapy.
Using inverse-probability treatment weights and other adjustments, the team determined that following trimodal therapy there was significantly decreased overall survival (hazard ratio, 1.54) and cancer-specific survival (HR, 1.51).
At one year, the median cost of trimodal therapy was $289,142 compared to $148,757 for radical cystectomy (P<0.001), with a median difference of $109,027.
"Increased costs associated with trimodal therapy were largely due to radiology ($56,747) and pharmacy ($19,762) costs," Dr. Williams said. "When extrapolated nationally, this resulted in $468 million increased total costs associated with trimodal therapy versus radical cystectomy. Moreover, as we have previously shown, trimodal therapy resulted in significantly worse survival than radical cystectomy."
Dr. Alexander P. Cole of Harvard Medical School, in Boston, co-author of an editorial published with the study June 5 in JAMA Surgery, told Reuters Health by email that the trimodal technique "hasn't been evaluated in a head-to-head clinical trial yet, but there is now emerging data that survival may be worse compared to those who have their entire bladder and surrounding tissue removed in a single operation."
"This analysis," he continued, "suggests that it may be more expensive too. This makes sense. You are basically replacing one major surgery with a series of smaller surgeries, surveillance procedures, and radiation treatments. What's more, a decent portion of these patients may still need to have their bladder removed surgically."
"For patients," Dr. Cole concluded, "there is an obvious appeal to getting to keep their bladder, but it is important to remember that this isn't entirely a free lunch. Repeat endoscopic procedures, radiation and chemotherapy don't just carry a financial cost, but also have side effects and toxicities which need to be weighed alongside potential benefits."
JAMA Surg 2019.