Population-Based Outcomes and Costs Assessment Comparing Radical Cystectomy With Trimodal Therapy for Patients Diagnosed With Localized Muscle-Invasive Bladder Cancer

From the 2018 HVPAA National Conference

Stephen Williams (UTMB), preston kerr (UTMB), Yong Shan (UTMB), Usama Jazzar (UTMB), Hemalkumar Mehta (UTMB), Jacques Baillargeon (UTMB), Jinhai Huo (University of Florida), Sapna Kaul (UTMB), Christopher Kosarek (UTMB), Eduardo Orihuela (UTMB), Douglas Tyler (UTMB), Todd Swanson (UTMB), Ashish Kamat (University of Texas MD Anderson Cancer Center)


Radical cystectomy is the guideline-recommended treatment for muscle-invasive bladder cancer. Recently there has been increased use of trimodal therapy with limited data on comparative outcomes, and especially attributable costs.


We sought to compare survival outcomes and costs of trimodal therapy versus radical cystectomy in older adults with muscle-invasive bladder cancer.


A total of 2,963 patients aged 66 years or older diagnosed with clinical stage T2-4a bladder cancer from January 1, 2002- December 31, 2011 from the Surveillance, Epidemiology, and End Results (SEER)-Medicare data were analyzed.Cox regression analysis and inverse probability of treatment weighting (IPTW) were used to determine predictors for overall and cancer-specific survival for those that underwent trimodal therapy or radical cystectomy.


A total of 2,963 patients met inclusion criteria. Patients who underwent trimodal therapy had significantly decreased overall (Hazard Ratio (HR) 1.54, 95% Confidence Interval (CI), 1.39-1.71, p<0.001) and cancer-specific (HR 1.51, 95% CI 1.40-1.63, p<0.001) survival, respectively. Median total costs were significantly higher with trimodal therapy than radical cystectomy at 90-d ($76,701 vs. $62,906, p<0.001) and 180-d ($171,401 vs. $99,890, p<0.001), respectively. Extrapolating these figures to the total US population results in excess spending of $370 million for trimodal therapy compared to less costly radical cystectomy for patients diagnosed in 2011.


Using IPTW in a large population-based cohort, trimodal therapy was associated with significantly decreased overall and cancer-specific survival resulting in excess national spending of $370 million in 2011 compared with radical cystectomy.

Implications for the Patient

Radical cystectomy is the guideline-recommended treatment for muscle-invasive bladder cancer however recently there has been increased utilization of trimodal therapy. Our data indicates trimodal therapy increases costs and is associated with decreased overall and cancer-specific survival.


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