Treatment Outcomes and Estimated Costs Associated with BCG Therapy for Patients with High-Risk Non-Muscle-Invasive Bladder Cancer - Expert Commentary

Non-muscle invasive bladder cancers (NMIBC) constitute the majority of bladder cancer diagnoses. NMIBCs are stratified based on the risk of progression to muscle-invasive disease into low, intermediate, and high-risk groups. NMIBC has the highest lifetime treatment costs of all cancers in the USA.

A recent study by Williams et al. published in JAMA Network Open, conducted a retrospective analysis of patients with high-risk NMIBC from patients who received at least one dose of intravesical bacillus Calmette-Guérin (BCG) in the Department of Veterans Affairs (VA) centers across the USA. The study investigated the long-term outcomes and attributable costs associated with BCG therapy. Adequate BCG therapy was defined as at least 5 BCG instillations within 70 days for induction therapy and 7 BCG instillations within 274 days for maintenance therapy.

A total of 412 patients were included in the final analysis. The majority were male (81%), with a median age of 67 (IQR, 61-74). The study spanned the period from 2000 to 2015 with a follow-up of 2694 person-years. Most patients (95%) received adequate induction BCG therapy, but only 37% received adequate maintenance BCG therapy. Carcinoma in situ (CIS) was found to be an adverse prognostic factor and was associated with lower disease-free survival (hazard ratio [HR], 1.85; 95% confidence interval: 1.34-2.56).

The median total cost at 5 years was $117,361 (IQR, $59,680-$211,298). This was significantly higher in patients with disease progression ($232,729 vs $94,879, P < .001). The higher costs associated with disease progression were mainly attributed to outpatient care, pharmacy, and surgery-related costs. The study extrapolated per-patient cost to the US population resulting in an estimated total cost of $465 for patients diagnosed in 2019with high-risk NMIBC who underwent radical cystectomy in the US.

This large real-world study describes outcomes and costs from an equal-access setting. The study emphasizes the importance of providing adequate BCG maintenance therapy to high-risk NMIBC patients. Eventually, this will translate into lower disease progression rates and reduce the number of radical cystectomies and decrease expenditures. New effective treatment options are still needed to reduce the risk of progression for NMIBC patients. Cost-effective management strategies will reduce the considerable economic burden of this disease.  

Written by: Bishoy M. Faltas, MD, Director of Bladder Cancer Research, Englander Institute for Precision Medicine, Weill Cornell Medicine, New York City, New York


  1. Williams SB, Howard LE, Foster ML, Klaassen Z, Sieluk J, De Hoedt AM, et al. Estimated Costs and Long-term Outcomes of Patients With High-Risk Non–Muscle-Invasive Bladder Cancer Treated With Bacillus Calmette-Guérin in the Veterans Affairs Health System. JAMA Netw Open. 2021 Mar 31;4(3):e213800. PMID: 33787908

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