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Radical Cystectomy Provides Improved Survival Outcomes and Decreased Costs Compared With Trimodal Therapy for Patients Diagnosed With Localized Muscle-Invasive Bladder Cancer

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

Background

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.

Objectives

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

Methods

A total of 3,200 patients aged 66 years or older diagnosed with clinical stage T2-4a bladder cancer from January 1, 2002- December 31, 2011 from SEER-Medicare linked-data. Propensity score matching based on sociodemographic and clinical characteristics were used. The association of treatment with overall and cancer-specific survival was evaluated using the Cox proportional hazards regression and Fine and Gray’s competing risk model.

Results

A total of 3,200 patients met inclusion criteria. After propensity score matching, 687 patients underwent trimodal therapy and 687 patients underwent radical cystectomy. Patients who underwent trimodal therapy had significantly decreased overall (Hazard Ratio (HR) 1.49, 95% Confidence Interval (CI), 1.31-1.69) and cancer-specific (HR 1.55, 95% CI 1.32-1.83) survival, respectively. While there was no difference in costs at 30 days, median total costs were significantly higher with trimodal therapy than radical cystectomy at 90-d ($69,181 vs. $80,174; Median Difference $8,964, Hodges-Lehmann 95% CI, $3,848-14,079) and 180-d ($107,017 vs. $179,891; Median Difference $63,771, Hodges-Lehmann 95% CI, $55,512-72,029), respectively. Extrapolating these figures to the total US population results in excess spending of $335 million for trimodal therapy compared to less costly radical cystectomy for patients diagnosed in 2011.

Conclusion

Trimodal therapy was associated with significantly decreased overall and cancer-specific survival resulting in excess national spending of $335 million in 2011 compared with radical cystectomy. These findings have important health policy implications regarding appropriate use of high-value based care among patients who are candidates for either treatment

Implications for the Patient

There is an increase in the use of trimodal therapy in the treatment of bladder cancer however using a large nationwide propensity score matched cohort, trimodal therapy was associated with significantly decreased overall and cancer-specific survival at significantly increased costs compared with radical cystectomy.