Williams SB, et al. - In older adults with muscle-invasive bladder cancer, researchers compared the survival outcomes and costs between trimodal therapy and radical cystectomy. Findings suggested an association of trimodal therapy with significantly reduced overall survival and cancer-specific survival as well as $335 million in excess spending in 2011. Among older adults with invasive bladder cancer who are candidates for either radical cystectomy or trimodal therapy, these discoveries have significant health policy implications in regards to the appropriate use of high value–based care.

Methods

• Using data from the Surveillance, Epidemiology, and End Results–Medicare linked database, researchers performed this population-based cohort study.
• For this investigation, they included 3200 older adults (aged ≥66 years) with clinical stage T2 to T4a bladder cancer diagnosed from January 1, 2002, to December 31, 2011, and with claims data available through December 31, 2013.
• Study participants were patients who received radical cystectomy had either only surgery or surgery in combination with radiotherapy or chemotherapy.
• In this analysis, patients who received trimodal therapy had transurethral resection of the bladder followed by radiotherapy and chemotherapy.
• They used propensity score matching by sociodemographic and clinical characteristics.
• From August 1, 2017, to March 11, 2018, data analysis was performed.
• Using the Cox proportional hazards regression model and the Fine and Gray competing risk model, they assessed overall survival and cancer-specific survival.
• Comparison of all Medicare health care costs for inpatient, outpatient, and physician services within 30, 90, and 180 days of treatment was performed.
• They evaluated the total amount spent nationwide, using 180-day medical costs between treatments, by the total number of new cases of muscle-invasive bladder cancer in the US in 2011.

Results

• The inclusion criteria was met by 3200 patients (2048 (64.0%) were men and 1152 (36.0%) were women, with a mean (SD) age of 75.8 (6.0) years).
• Trimodal therapy was was given to 687 patients (21.5%) and radical cystectomy was performed on 687 patients (21.5%) after propensity score matching.
• Researchers noted significantly decreased overall survival (hazard ratio [HR], 1.49; 95% CI, 1.31-1.69) and cancer-specific survival (HR, 1.55; 95% CI, 1.32-1.83) for patients who underwent trimodal therapy.
• They did not find differences in costs at 30 days between trimodal therapy ($15 233 in 2002 vs $18 743 in 2011) and radical cystectomy ($17 990 in 2002 vs $21 738 in 2011).
• However, with trimodal therapy vs radical cystectomy, median total costs were significantly higher at 90 days ($80 174 vs $69 181; median difference, $8964; Hodges-Lehmann 95% CI, $3848-$14 079) and at 180 days ($179 891 vs $107 017; median difference, $63 771; Hodges-Lehmann 95% CI, $55 512-$72 029).
• For patients who received a muscle-invasive bladder cancer diagnosis in 2011, extrapolating these figures to the total US population revealed $335 million in excess spending for trimodal therapy vs the less costly radical cystectomy ($492 million).