[Skip to Content]
[Skip to Content Landing]
Views 1,542
Citations 0
Original Investigation
June 5, 2019

Comparison of Costs of Radical Cystectomy vs Trimodal Therapy for Patients With Localized Muscle-Invasive Bladder Cancer

Author Affiliations
  • 1Division of Urology, Department of Surgery, The University of Texas Medical Branch at Galveston, Galveston
  • 2Department of Surgery, The University of Texas Medical Branch at Galveston, Galveston
  • 3Department of Urology, Cedars Sinai Medical Center, Los Angeles, California
  • 4Department of Radiation Oncology, The University of Texas Medical Branch at Galveston, Galveston
  • 5Sealy Center on Aging, Division of Epidemiology, Department of Medicine, The University of Texas Medical Branch at Galveston, Galveston
  • 6Department of Urology, Weill Cornell Medicine, New York, New York
  • 7Department of Preventive Medicine and Community Health, The University of Texas Medical Branch at Galveston, Galveston
  • 8Department of Urology, The University of Texas MD Anderson Cancer Center, Houston
  • 9Department of Urology, University of Washington, Seattle
JAMA Surg. 2019;154(8):e191629. doi:10.1001/jamasurg.2019.1629
Key Points

Question  What is the association of patient survival and intensity of treatment with total Medicare costs that are associated with radical cystectomy vs trimodal therapy for older adults with localized muscle-invasive bladder cancer?

Findings  This Surveillance, Epidemiology, and End Results–Medicare cohort study identified 2963 patients aged 66 to 85 years with a diagnosis of clinical stage T2 to T4a bladder cancer. The inverse probability of treatment-weighted propensity score models revealed that outpatient, radiology, and pathology/laboratory services, along with medication expenses, significantly contributed to $136 935 higher costs associated with trimodal therapy compared with radical cystectomy within 1 year after bladder cancer diagnosis.

Meaning  The excess spending associated with trimodal therapy largely attributed to medication and radiology expenses along with the less favorable survival outcomes compared with radical cystectomy should be discussed during clinical decision making for patients with bladder cancer.

Abstract

Importance  Earlier studies on the cost of muscle-invasive bladder cancer treatments lack granularity and are limited to 180 days.

Objective  To compare the 1-year costs associated with trimodal therapy vs radical cystectomy, accounting for survival and intensity effects on total costs.

Design, Setting, and Participants  This population-based cohort study used the US Surveillance, Epidemiology, and End Results–Medicare database and included 2963 patients aged 66 to 85 years who had received a diagnosis of clinical stage T2 to T4a muscle-invasive bladder cancer from January 1, 2002, through December 31, 2011. The data analysis was performed from March 5, 2018, through December 4, 2018.

Main Outcomes and Measures  Total Medicare costs within 1 year of diagnosis following radical cystectomy vs trimodal therapy were compared using inverse probability of treatment–weighted propensity score models that included a 2-part estimator to account for intrinsic selection bias.

Results  Of 2963 participants, 1030 (34.8%) were women, 2591 (87.4%) were white, 129 (4.4%) were African American, and 98 (3.3%) were Hispanic. Median costs were significantly higher for trimodal therapy than radical cystectomy in 90 days ($83 754 vs $68 692; median difference, $11 805; 95% CI, $7745-$15 864), 180 days ($187 162 vs $109 078; median difference, $62 370; 95% CI, $55 581-$69 160), and 365 days ($289 142 vs $148 757; median difference, $109 027; 95% CI, $98 692-$119 363), respectively. Outpatient care, radiology, medication expenses, and pathology/laboratory costs contributed largely to the higher costs associated with trimodal therapy. On inverse probability of treatment–weighted adjusted analyses, patients undergoing trimodal therapy had $136 935 (95% CI, $122 131-$152 115) higher mean costs compared with radical cystectomy 1 year after diagnosis.

Conclusions and Relevance  Compared with radical cystectomy, trimodal therapy was associated with higher costs among patients with muscle-invasive bladder cancer. The differences in costs were largely attributed to medication and radiology expenses associated with trimodal therapy. Extrapolating cost figures resulted in a nationwide excess spending of $468 million for trimodal therapy compared with radical cystectomy for patients who received a diagnosis of bladder cancer in 2017.

Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    ×