Comparing costs of radical cystectomy versus trimodal therapy for patients diagnosed with localized muscle-invasive bladder cancer

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Background: Studies on the cost of muscle-invasive bladder cancer treatments lack granularity and are limited to 180 days. This study aimed to compare the one-year costs of trimodal therapy versus radical cystectomy, accounting for survival and intensity effects on total costs. Methods: Using Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data, we included a total of 2,963 patients aged ≥66 years diagnosed with clinical stage T2-4a bladder cancer between 2002 and 2011. We compared total Medicare costs within one year of diagnosis among patients following radical cystectomy or trimodal therapy using inverse probability of treatment weighted (IPTW) propensity score models, which included a two-part estimator to account for intrinsic selection bias. Results: Median total costs were significantly higher for trimodal therapy than radical cystectomy in 90 days ($83,754 vs. $68,692; median difference $11,805, 95% CI $7,745 to $15,864), 180 days ($187,162 vs. $109,078; median difference $62,370, 95% CI $55,581 to $69,160), and 365 days ($289,142 vs. $148,757; median difference $109,027, 95% CI $98,692 to $119,363), respectively. Outpatient, radiology, pharmacy and pathology/laboratory costs contributed largely to the significantly higher costs associated with trimodal therapy. On IPTW-adjusted analyses, patients undergoing trimodal therapy had $142,337 (95% CI $117,423-$175,300) higher costs compared with radical cystectomy one year after treatment (Table). Conclusions: Compared to radical cystectomy, trimodal therapy was associated with higher costs among patients with muscle-invasive bladder cancer. Extrapolating cost figures to the total US population resulted in excess spending of $853 million for trimodal therapy compared with radical cystectomy for patients diagnosed in 2018. [Table: see text]

Comparing radical cystectomy with trimodal therapy for patients diagnosed with bladder cancer: Critical assessment of statistical methodology and interpretation of observational data

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Background: Treatment guidelines for muscle-invasive bladder cancer recommend radical cystectomy. However, use of trimodal therapy has increased in recent years with conflicting survival outcomes. The aim of this study was to compare radical cystectomy and trimodal therapy in terms of survival outcomes and cost of treatment according to varying statistical methodology in order to interpret findings using observational data. Methods: Patients aged 66 years or older diagnosed with clinical stage T2-4a bladder cancer from January 1, 2002-December 31, 2011 were included from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Outcomes included cancer-specific survival, overall survival, and 6-month costs. Cox proportional hazards regression, propensity score matching (PSM) and inverse probability of treatment weighting (IPTW) were used to control for baseline differences between patients undergoing radical cystectomy vs. trimodal therapy, and to determine predictors for overall and cancer-specific survival. Results: A total of 2,963 patients were included: 728 (24.6%) who underwent trimodal therapy were compared to 2,235 (75.4%) who underwent radical cystectomy. In all adjusted analyses, patients who underwent trimodal therapy had significantly decreased cancer-specific survival (Cox regression: Hazard Ratio (HR) 1.51, 95% Confidence Interval (CI) 1.40-1.63; PSM: HR 1.55, 95% CI 1.32-1.83; IPTW: HR 1.51, 95% CI 1.40-1.63) and overall survival (Cox regression: HR 1.54, 95% CI 1.39-1.71; PSM: HR 1.49, 95% CI 1.31-1.69; IPTW: HR 1.54, 95% CI 1.39-1.71). However, median total costs over six months were significantly higher with trimodal therapy than radical cystectomy ($171,401 vs. $99,890, p<0.001). Conclusions: Trimodal therapy was associated with decreased cancer-specific and overall survival at increased costs compared to radical cystectomy. In the absence of data from randomized controlled trials, this observational study provides further evidence to suggest the superiority of radical cystectomy over trimodal therapy in patients with muscle-invasive bladder cancer.

Overall survival advantage with radical prostatectomy for prostate cancer

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Background: To compare overall survival of patients who underwent radical prostatectomy or radiotherapy versus non-cancer controls in order to discern if there is a survival advantage according to prostate cancer treatment. Methods: A matched cohort study was performedusingthe Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database. We identified 34,473 patients age 66 to 75 years without significant comorbidity from who were diagnosed with localized prostate cancer treated with surgery or radiotherapy between 2004 and 2011. These patients were matched to a non-cancer control cohort. We compared the rates of all-cause mortality that occurred within the study period. We used Cox Proportional Hazards Regression analysis to identify determinants associated with overall survival. Results: Of the total 34,473 patients who were included in the analysis, 21,740 (63%) received radiation therapy and 12,733 (37%) received surgery. When compared to the non-cancer control, there was no significant difference between the prostate cancer cohort and the non-cancer control group with exception of race/ethnicity (p < 0.001). There was improved survival in patients treated with surgery (hazard ratio [HR], 0.35; 95% CI, 0.32-0.38) as well as with radiotherapy (HR, 0.72; 95% CI, 0.68-0.75) when compared to non-cancer controls. There was significantly improved overall survival among both treatment groups with most benefit observed among patients who underwent surgery ( log rank p < 0.001). Conclusions: Using population based data, treatment with either surgery or radiotherapy demonstrated improved overall survival when compared to a cohort of matched non-cancer controls. Treatment with surgery resulted in longer overall survival compared to those receiving radiation therapy. These results suggest inherent selection-bias due to unmeasured confounding variables when using cancer registry data.

Increased utilization of advanced imaging technology and its economic impact for patients diagnosed with bladder cancer in the United States

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Background: This study examined utilization patterns and predictors for use of positron emission tomography-computed tomography (PET/CT), magnetic resonance imaging (MRI), and computed tomography (CT) among Medicare beneficiaries diagnosed with bladder cancer. Methods: We used the Surveillance, Epidemiology and End Results (SEER)-Medicare linked databases to analyze claims data for 36,855 patients aged 60-90 years diagnosed with bladder cancer from 2004 to 2011. The Cochran-Armitage test for trend was used to determine whether significant changes in the proportion of patients receiving advanced imaging after cancer diagnosis occurred during the time interval; trends in the usage of the imaging modality types were assessed. Multivariable logistic regression modeling was conducted to analyze potential demographic and clinical predictors associated with receipt of advanced imaging. The costs of imaging were measured using Medicare payments. Results: While the overall trend of imaging use remained essentially unchanged over the study period, there was a significant decrease in the proportion of patients who received conventional imaging modalities (MRI and CT; P < .05) and a significant increase in the proportion of patients receiving the more advanced imaging modality (PET/CT; P < .0001). On multivariable analysis, receipt of PET/CT was significantly higher in female patients, Non-Hispanics, residents in West Census region, patients with higher grade tumors, those diagnosed with advanced stage disease, hydronephrosis, and those that received radical cystectomy and chemotherapy. In the cost analysis, the estimated national excess medical spending for advanced imaging was $6.1 million. Conclusions: The sharp increase of advanced imaging (PET/CT) and substantial costs associated with this rapid adoption as we have documented suggests that further efforts should be made to evaluate the clinical and economic benefits of PET/CT imaging and to elucidate its appropriateness of use among bladder cancer patients.

Discerning predictors for gender differences in survival outcomes for patients treated for bladder cancer

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Background: Radical cystectomy is an underutilized option for those with refractory non-muscle invasive and muscle-invasive bladder cancer, however, use of radical cystectomy may differ according to gender. We wanted to discern receipt and timing of radical cystectomy as well as survival outcomes according to gender. Methods: A total of 49,974 patients aged 66 years or older diagnosed with clinical stage I-IV bladder cancer from January 1, 2002 to December 31, 2011 using Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data. We used univariate and multivariable regression analyses to identify factors predicting the use of radical cystectomy. Cox proportional hazards models were used to analyze survival outcomes. Generalized linear models were performed to determine association between gender and delayed radical cystectomy. Results: A total of 49,974 patients were diagnosed with stage I to IV bladder cancer. 36,959 (74%) were male patients. Women were older, non-Caucasian race/ethnicity, with increased comorbidities and presented with more advanced disease (all p<0.001). Women were more likely than men to receive radical cystectomy across all clinical stages (stage I, relative risk [RR] 1.53, 95% confidence interval [CI] 1.27-1.84, p<0.001; stage II, RR 1.52, 95% CI 1.37-1.70, p<0.001; stage III, RR 1.26, 95% CI 1.15-1.39, p<0.001; stage IV, RR 1.31, 95% CI 1.17-1.47, p<0.001). Women had lower cancer-specific survival with stage II (hazard ratio [HR] 1.20, 95% CI 1.09-1.32, p<0.001), stage III (HR 1.44, 95% CI 1.23-1.68, p<0.001), and stage IV (HR 1.29, 95%CI 1.17-1.43, p<0.001) disease. Delay from diagnosis to radical cystectomy was associated with worse survival. Conclusions: Gender differences persist with women significantly more likely to undergo radical cystectomy independent of clinical stage. After controlling for tumor characteristics and neoadjuvant chemotherapy, women have significantly worse cancer-specific survival than men. Delay to surgery did not account for this decreased survival among women. These findings support further research discerning bladder carcinogenesis according to gender.

Impact of proximity to NCI- and NCCN-designated cancer centers on outcomes for patients with prostate cancer undergoing radical prostatectomy

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Background: National Cancer Institute (NCI) and National Comprehensive Cancer Network (NCCN)-designated cancer centers (CCs) offer patients state-of-the-art treatment. We sought to identify whether proximity to NCI/NCCN CCs was associated with survival outcomes for prostate cancer patients who undergo radical prostatectomy (RP). Methods: A total of 12,478 total patients diagnosed with clinical stage T1 or T2 prostate cancer between 2004–2011 using linked Surveillance, Epidemiology, and End Results (SEER)-Medicare data were included. Multivariable regression analyses were used to quantify overall survival and use of secondary therapies for RP patients according to proximity to NCI/NCCN CCs. Cox proportional hazards models were used to quantify the association between survival outcomes and access to NCI/NCCN CCs. Results: Patients with proximity to ≥ 2 NCI centers and those diagnosed in 2011 enjoyed a statistically significant overall survival advantage when compared to no access to an NCI center (Hazard Ratio (HR) 0.72; 95% confidence interval (CI) 0.57–0.92, p < 0.01). Proximity to an NCCN CC, when compared with men who did not have access, was associated with improved overall survival (HR 0.76; 95% CI 0.61–0.95, p = 0.015). There was no significant difference in use of secondary therapies according to NCI or NCCN access. Conclusions: Patients who undergo RP with access to an NCI/NCCN CCs experienced improved overall survival with no significant difference in utilization of secondary therapies. Given the need for improved health quality measures in cancer care, these findings may support health policy implementation and regionalization of care to these centers.