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Cost‐effectiveness analysis of immediate radical cystectomy versus intravesical Bacillus Calmette‐Guerin therapy for high‐risk, high‐grade (T1G3) bladder cancer
Author(s) -
Kulkarni Girish S.,
Alibhai Shabbir M. H.,
Finelli Antonio,
Fleshner Neil E.,
Jewett Michael A. S.,
Lopushinsky Steven R.,
Bayoumi Ahmed M.
Publication year - 2009
Publication title -
cancer
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 3.052
H-Index - 304
eISSN - 1097-0142
pISSN - 0008-543X
DOI - 10.1002/cncr.24634
Subject(s) - cystectomy , medicine , bladder cancer , urology , comorbidity , malignancy , cancer
BACKGROUND: Although both radical cystectomy and intravesical immunotherapy are initial treatment options for high‐risk, T1, grade 3 (T1G3) bladder cancer, controversy regarding the optimal strategy persists. Because bladder cancer is the most expensive malignancy to treat per patient, decisions regarding the optimal treatment strategy should consider costs. METHODS: A Markov Monte‐Carlo cost‐effectiveness model was created to simulate the outcomes of a cohort of patients with incident, high‐risk, T1G3 bladder cancer. Treatment options included immediate cystectomy and conservative therapy with intravesical Bacillus Calmette‐Guerin (BCG). The base case was a man aged 60 years. Parameter uncertainty was assessed with probabilistic sensitivity analyses. Scenario analyses were used to explore the 2 strategies among patients stratified by age and comorbidity. RESULTS: The quality‐adjusted survival with immediate cystectomy and BCG therapy was 9.46 quality‐adjusted life years (QALYs) and 9.39 QALYs, respectively. The corresponding mean per‐patient discounted lifetime costs (in 2005 Canadian dollars) were $37,600 and $42,400, respectively. At a willingness‐to‐pay threshold of $50,000 per QALY, the probability that immediate cystectomy was cost‐effective was 67%. Immediate cystectomy was the dominant (more effective and less expensive) therapy for patients aged <60 years, whereas BCG therapy was dominant for patients aged >75 years. With increasing comorbidity, BCG therapy was dominant at lower age thresholds. CONCLUSIONS: Compared with BCG therapy, immediate radical cystectomy for average patients with high‐risk, T1G3 bladder cancer yielded better health outcomes and lower costs. Tailoring therapy based on patient age and comorbidity may increase survival while yielding significant cost‐savings for the healthcare system. Cancer 2009. © 2009 American Cancer Society.