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?
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.
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.
Earlier studies on the cost of muscle-invasive bladder cancer treatments lack granularity and are limited to 180 days.
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.
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.
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Williams SB, Shan Y, Ray-Zack MD, et al. Comparison of Costs of Radical Cystectomy vs Trimodal Therapy for Patients With Localized Muscle-Invasive Bladder Cancer. JAMA Surg. Published online June 05, 2019. doi:10.1001/jamasurg.2019.1629
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