AUA 2018: Radical Cystectomy Provides Improved Survival Outcomes and Decreased Costs Compared with Trimodal Therapy for Patients Diagnosed with Localized Muscle-Invasive Bladder Cancer

San Francisco, CA USA (UroToday.com) Based on the inherent morbidity and legitimate risk of 90-day mortality among patients undergoing radical cystectomy, there has been a recent interest in other “non-invasive”, bladder-sparing modalities for treating muscle invasive bladder cancer (MIBC). Specifically, there have been several studies assessing outcome of trimodal therapy, with generally comparable results to patients undergoing radical cystectomy among institutional and population-level analyses.

Patients that may be eligible for trimodal therapy include those with:
• Small, solitary muscle-invasive tumors
• No significant CIS
• No hydronephrosis
• Complete TURBT without remaining tumor

Nonetheless, radical cystectomy remains the guideline-recommended treatment for MIBC. At today’s invasive bladder cancer session at the 2018 AUA, Dr. Williams and colleagues from UT-Galveston presented results of their population-level analysis assessing costs for trimodal therapy compared to radical cystectomy.

For this study, the author’s used the Surveillance, Epidemiology, and End Results (SEER)-Medicare database to identify 3,200 patients aged 66 years or older diagnosed with clinical stage T2-4a bladder cancer from January 1, 2002 to December 31, 2011. Identification of treatments was through diagnosis and procedural codes. Covariates included were: age, sex, race/ethnicity, marital status, US region, socioeconomic status, education level, household median income, and comorbidity (assessed using the Klabunde modification of Charlson comorbidity index). In addition to the cost analysis performed at 30, 80, and 180 days, the authors performed a Cox regression analysis and propensity score matching to determine predictors for overall and cancer-specific survival.

After propensity score matching, there were 687 patients who underwent trimodal therapy and 687 patients who underwent radical cystectomy. Patients who underwent trimodal therapy had significantly decreased cancer-specific (HR 1.55, 95%CI 1.32-1.83) and overall (HR 1.49, 95%CI 1.31-1.69) survival. There was no difference in costs at 30 days, however the median total costs were significantly higher with trimodal therapy than radical cystectomy at 90-days ($69,181 vs. $80,174, p < 0.001) and 180-days ($101,017 vs. $179,891, p < 0.001). In discussion with the authors, this is likely secondary to vigorous cystoscopic and radiographic follow-up associated with patients undergoing trimodal therapy compared to those undergoing radical cystectomy. When Dr. Williams extrapolated these cost-estimates to the total US population, this would result in excess spending of $335 million for trimodal therapy compared to less costly radical cystectomy (based on patients diagnosed in 2011).

The strength of this study is that the authors were able to utilize a population-level analysis to have sufficient patients in each group and subsequently perform meaningful, generalizable findings. A possible limitation of the study is that these results are for patients 66 years of age and older, whereas the findings may not be as applicable to younger patients with longer life expectancy. Dr. Williams concluded that trimodal therapy was associated with significantly decreased overall and cancer-specific survival resulting in excess national spending compared with radical cystectomy. Importantly, these findings have meaningful health policy implications regarding appropriate use of high-value based care among patients who are candidates for either treatment.

Presenter(s): Stephen B. Williams, University of Texas Medical Branch, Galveston, TX

Co-Authors: Christopher Kosarek, Yong Shan, Usama Jazzar, Hemalkumar Mehta, Jacques Baillargeon, Galveston, TX, Jinhai Huo, Gainesville, FL, Anthony Senagore, Eduardo Orihuela, Douglas Tyler, Todd Swanson, Galveston, TX, Ashish Kamat, Houston, TX

Written by: Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre, Twitter: @zklaassen_md, at the 2018 AUA Annual Meeting - May 18 - 21, 2018 – San Francisco, CA USA

References:
1. Kulkarni GS, Hermanns T, Wei Y, et al. Propensity score analysis of radical cystectomy versus bladder-sparing trimodal therapy in the setting of a multidisciplinary bladder cancer clinic. J Clin Oncol 2017;35(20):2299-2305.
2. Fahmy O, Khairul-Asri MG, Schubert T, et al. A systematic review and meta-analysis on the oncological long-term outcomes after trimodality therapy and radical cystectomy with or without neoadjuvant chemotherapy for muscle-invasive bladder cancer. Urol Oncol 2018;36(2):43-53.
3. Seisen T, Sun M, Lipsitz SR, et al. Comparative effectiveness of trimodal therapy versus radical cystectomy for localized muscle-invasive urothelial carcinoma of the bladder. Eur Urol 2017;72(4):483-487.
4. Kulkarni GS, Klaassen Z. Trimodal Therapy is inferior to radical cystectomy for muscle invasive bladder cancer using population-level data: Is there evidence in the (lack of) details? Eur Urol 2017;72(4):488-489.
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