Williams SB, et al. - Survival outcomes and costs related to trimodal therapy vs radical cystectomy were compared in older adults with muscle-invasive bladder cancer. Findings revealed significantly lower overall and cancer-specific survival rates at significantly higher costs in association with trimodal therapy vs radical cystectomy.

Methods

• Using data from the Surveillance, Epidemiology, and End Results–Medicare linked database, researchers performed this population-based cohort study.
• For this analysis, they included 3,200 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.
• Management of patients who received radical cystectomy included either only surgery or surgery in combination with radiotherapy or chemotherapy.
• In this work, patients receiving trimodal therapy underwent transurethral resection of the bladder followed by radiotherapy and chemotherapy.
• They used propensity score matching by sociodemographic and clinical characteristics.
• Using the Cox proportional hazards regression model and the Fine and Gray competing risk model, they evaluated 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 assessed 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 United States in 2011.

Results

• The inclusion criteria was met by 3,200 patients (2,048 [64%] were men and 1,152 [36%] were women; mean age was 75.8 [6.0] years).
• Trimodal therapy 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.
• Costs at 30 days were not significantly different 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, $3,848-$14,079) and at 180 days ($179,891 vs $107,017; median difference, $63,771; Hodges-Lehmann 95% CI, $55,512-$72,029).
• Extrapolating these figures to the total US population indicate that for patients who received a muscle-invasive bladder cancer diagnosis in 2011, trimodal therapy resulted in $335 million in excess spending compared with the less costly radical cystectomy ($492 million).