SUO 2017: Cost Effective Analysis of Neoadjuvant Chemotherapy Prior to Radical Cystectomy in T2 Bladder Cancer

Washington, DC ( Dr. Hamilton and colleagues presented results of their decision analysis for neoadjuvant chemotherapy prior to radical cystectomy (RC) for T2 bladder cancer. Although there is level 1 evidence [1] and a comprehensive meta-analysis supporting a 5% overall survival benefit for neoadjuvant chemotherapy in bladder cancer [2], the cost effectiveness of this strategy is still debated. The objective of this study was to present a cost effectiveness analysis of neoadjuvant chemotherapy prior to RC in the setting of T2 bladder cancer.

The authors constructed a Markov model to simulate neoadjuvant platinum based chemotherapy followed by RC vs. primary RC, disease recurrence, and survival in patients with T2 bladder cancer. Transition probabilities were derived from clinical trial data, and costs (converted to 2016 US dollars) and health utilities were estimated from the literature. Incremental cost-effectiveness ratios (ICER), expressed as dollar per quality-adjusted life-year (QALY), were calculated with ICER less than $50,000/QALY considered cost effective. The authors subsequently conducted one-way and probabilistic sensitivity analyses to examine model uncertainty. The base-case model found that over a lifetime, platinum based neoadjuvant chemotherapy prior to RC increased overall costs by $16,527 and improved effectiveness by 1.0 QALYs compared with primary RC alone, leading to an ICER of $16,527. Using a tornado analysis plot of ICER, the model was most sensitive to age of patient, cost of neoadjuvant chemotherapy, and probability of mortality with neoadjuvant chemotherapy. Probabilistic sensitivity analysis found that neoadjuvant chemotherapy prior to RC was cost effective >90% of the time at a willingness-to-pay threshold of $50,000/QALY.

The authors concluded that platinum based neoadjuvant chemotherapy prior to RC in the setting of T2 urothelial cell carcinoma reduces costs with an acceptable ICER. Ultimately, this is a cost-effective treatment strategy for patients with T2 disease.


1. Grossman HB, Natale RB, Tangen CM, et al. Neoadjuvant chemotherapy plus cystectomy compared with cystectomy alone for locally advanced bladder cancer. N Engl J Med 2003;349(9):859-866.

2. Advanced Bladder Cancer (ABC) Meta-analysis Collaboration. Neoadjuvant chemotherapy in invasive bladder cancer: Update of a systematic review and meta-analysis of individual patient data advanced bladder cancer (ABC) meta-analysis collaboration. Eur Urol 2005;48(2):202-205.

Presented by: Zachary Hamilton MD¹

Co-Authors:  Unwanaobong Nseyo MD², Katherine Fero MD², James Murphy MD² and A. Karim Kader MD, PhD²

Affiliation:  ¹Saint Louis University, MO; ²University of California, San Diego

Written by: Zachary Klaassen, MD, Society of Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre @zklaassen_md at the 18th Annual Meeting of the Society of Urologic Oncology, November 20-December 1, 2017 – Washington, DC