The authors assembled a Markov model to compare the cost-effectiveness of mBCG to no-mBCG after induction BCG for intermediate/high-risk NMIBC from a US Medicare perspective. Details of the model are highlighted in this figure below.
Important transition probabilities including five-year recurrence, progression to MIBC, metastasis, mortality, and toxicity rates were extracted from meta-analyses and randomized trials. A literature review similarly provided utility values for health states. The authors performed univariable and multivariable sensitivity analyses. A willingness to pay threshold of $100,000 per quality-adjusted life-year (QALY) was considered cost-effective.
With a 5-year time horizon, mean costs per patient were $13,949 and $12,858 for mBCG and no-mBCG, respectively. Quality-adjusted life years were the same in both strategies (4.104 QALYs), as a result, no-mBCG was the dominant strategy.
On univariable sensitivity analysis, mBCG became cost-effective if the absolute reduction in five-year recurrence was >41.1% or the reduction in progression was >3.2%.
Utilizing 1/3rd dose mBCG resulted in marginal decreases in cost with mean 5-year costs per patient of $13,229. 1/3rd dose mBCG resulted in 4.103 QALY’s compared to 4.104 QALYs for no-mBCG, again supporting no-mBCG as the dominant strategy.
On univariable sensitivity analysis, 1/3rd dose mBCG became cost-effective if the absolute reduction in 5-year recurrence was >25.1% or the reduction in progression was >1.3%.
Neither full-dose mBCG (ICER $527,919) nor 1/3rd dose mBCG (ICER $247,766) were cost-effective, even if the probability of mBCG toxicity was reduced to 0.
Finally, the authors performed multivariable sensitivity analyses using 10,000 Monte-Carlo microsimulations. In this analysis, mBCG was cost-effective in 13% of microsimulations while 1/3rd dose mBCG was cost-effective in 32% of microsimulations supporting the overall analysis.
While reliant on modeling rather than direct comparative data, the authors found that neither full dose mBCG nor 1/3rd dose mBCG appears cost-effective for intermediate/high-risk NMIBC based on reported efficacy and toxicity data. Thus, the utilization of limited BCG resources should be prioritized for induction treatment.
Presented by: Vidit Sharma, MD, Mayo Clinic, Rochester, MN
Written by: Christopher J.D. Wallis, Urologic Oncology Fellow, Vanderbilt University Medical Center, @WallisCJD on Twitter at the 2020 American Urological Association (AUA) Annual Meeting, Virtual Experience #AUA20, June 27- 28, 2020