Comparison of Costs of Radical Cystectomy vs Trimodal Therapy for Patients With Localized Muscle-Invasive Bladder Cancer

Williams, Stephen B.; Shan, Yong; Ray-Zack, Mohamed D.; Hudgins, Hogan K.; Jazzar, Usama; Tyler, Douglas S.; Freedland, Stephen J.; Swanson, Todd A.; Baillargeon, Jacques; Hu, Jim C.; Kaul, Sanjana; Kamat, Ashish M.; Gore, John L.; Mehta, Hemalkumar B.

doi:10.1001/jamasurg.2019.1629

Cited by 39 publications

(33 citation statements)

References 37 publications

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“…This needs to be addressed in the counselling of MIBC patients regarding the risks, benefits and alternatives to primary RC. Patients also need to be counselled on the high local recurrence rate following BST, which necessitates a lifelong follow-up and further invasive procedures, thus increasing morbidity and health care costs [44][45][46].…”

Section: Discussionmentioning

confidence: 99%

Incidence and outcome of salvage cystectomy after bladder sparing therapy for muscle invasive bladder cancer: a systematic review and meta-analysis

et al. 2020

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Objective We conducted a systematic review and meta-analysis to assess the available literature regarding the surgical and oncologic outcomes of patients undergoing salvage radical cystectomy (SV-RC) for recurrence or failure of bladder sparing therapy (BST) for muscle-invasive bladder cancer (MIBC). Methods We searched MEDLINE (PubMed), EMBASE and Google Scholar databases in May 2020. We included all studies of patients with ≥ cT2N0/xM0 bladder cancer that were eligible for all treatment modalities at the time of treatment decision who underwent BST including radiotherapy (RTX). A meta-analysis was conducted to calculate the pooled rate of several variables associated with an increased need for SV-RC. Study quality and risk of bias were assessed using MINORS criteria. Results 73 studies comprising 9110 patients were eligible for the meta-analysis. Weighted mean follow-up time was 61.1 months (range 12–144). The pooled rate of non-response to BST and local recurrence after BST, the two primary reasons for SV-RC, was 15.5% and 28.7%, respectively. The pooled rate of SV-RC was 19.2% for studies with a follow-up longer than 5 years. Only three studies provided a thorough report of complication rates after SV-RC. The overall complication rate ranged between 67 and 72% with a 30-day mortality rate of 0–8.8%. The pooled rates of 5 and 10-year disease-free survival after SV-RC were 54.3% and 45.6%, respectively. Conclusion Approximately one-fifth of patients treated with BST with a curative intent eventually require SV-RC. This procedure carries a proportionally high rate of complications and is usually accompanied by an incontinent urinary diversion.

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Section: Discussionmentioning

confidence: 99%

Incidence and outcome of salvage cystectomy after bladder sparing therapy for muscle invasive bladder cancer: a systematic review and meta-analysis

et al. 2020

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“…Based on these studies, it is clear that TMT is safe and effective for bladder cancer patients without serious side effects. However, we should note that TMT generates higher treatment costs, which is estimated at an excess spending of $468 million within 1 year of diagnosis in the US ( 40 ). Therefore, we should adopt multidisciplinary consultation with experts and also consider the patient's treatment expectations and financial circumstances, which may make bladder cancer patients access optimal treatment.…”

Section: Discussionmentioning

confidence: 99%

Trimodal Therapy vs. Radical Cystectomy for Muscle-Invasive Bladder Cancer: A Meta-Analysis

et al. 2020

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Background: To compare the difference between trimodal therapy (TMT) and radical cystectomy (RC) in treating muscle-invasive bladder cancer, we performed a meta-analysis for data from the following database. Methods: We searched PubMed, Chinese biomedicine literature database, the Cochrane Library, China National Knowledge Internet databases, Wanfang databases, and Google Scholar up to December 2019. The main outcome measures assessed were overall survival (OS), cancer-specific survival (CSS), mortality, and Charlson comorbidity score (CCS). Two authors independently evaluated the study quality and extracted data. All data were analyzed using Review Manager (version 5.3). Results: After database retrieval, article selection, data extraction, and quality assessment, nine articles comprising 5,721 cases from the TMT group and 48,262 cases from the RC group were included in this study. The data showed that there was no statistical difference between TMT and RC at <10 years OS [pooled hazard ratio (HR) = 1.26, 95% confidence interval (CI): 0.92–1.73, Z = 1.46, P = 0.14], while OS of the RC group was higher than that of the TMT group at more than 10 years (pooled HR = 1.34, 95% CI: 1.18–1.54, Z = 4.33, P < 0.0001). As for CSS, compared with the TMT group, the patients in the RC group had longer CSS (pooled HR = 1.50, 95% CI: 1.29–1.76, Z = 5.15, P < 0.00001). Compared with RC, TMT is linked to an obvious increase in all-cause mortality and bladder-specific cancer mortality (pooled HR = 1.30, 95% CI: 1.16–1.46, Z = 4.55, P < 0.00001; pooled HR = 1.32, 95% CI: 1.15–1.51, Z = 3.92, P < 0.0001). The bladder cancer patients belonging to CCS “0” score preferred RC [pooled relative risk (OR) = 0.94, 95% CI: 0.89–0.98, Z = 2.79, P = 0.005], while CCS “2” score's patients were prone to TMT (pooled OR = 1.40, 95% CI: 1.29–1.53, Z = 7.73, P < 0.00001). Conclusions: Overall, this meta-analysis suggests that the efficacy of TMT is non-inferior to that of RC at <10-year OS, and RC is superior to TMT at more than 10-year OS. Therefore, TMT may be a reasonable treatment option in well-selected patients who are unsuitable for surgery or are not willing to experience surgery. In the future, more high-quality, large-sample randomized controlled trials (RCTs) are needed to verify the results.

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“…The high financial burden of bladder cancer may explain why lack of insurance coverage has been linked with worse oncologic outcomes [2][3][4][5][6]. The ACA led to Medicaid expansion in 2014, which expanded coverage for select individuals in 36 states and the District of Columbia [7,9].…”

Section: Discussionmentioning

confidence: 99%

“…mated 17,700 deaths in 2019 across the United States [1]. Given the heavy financial burden of managing bladder cancer, insurance coverage has become an increasingly important aspect of coordinating patient care [2,3]. Unsurprisingly, worse bladder cancer outcomes have been observed in patients without health insurance [4][5][6].…”

Section: Introductionmentioning

confidence: 99%

Bladder Cancer Following Medicaid Expansion: No Changes in the Diagnosis of Muscle-Invasive Disease and Time to Treatment

Weiner

Desai

et al. 2020

BLC

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BACKGROUND: Bladder cancer patients who are insured experience improved outcomes. Medicaid expansion aimed to increase insurance coverage and improve access to care. However, the association between Medicaid expansion and stage at diagnosis or time to treatment for those with advanced bladder cancer is unknown. OBJECTIVE: We sought to determine to association of Medicaid expansion with stage at diagnosis, and time to treatment for patients with muscle-invasive bladder cancer. METHODS: A US-based cancer registry was utilized to evaluate the association between Medicaid expansion and cancer stage at diagnosis, insurance rates, and time to treatment (>60 days from diagnosis) for those diagnosed with bladder cancer. We compared outcomes in non-Medicare-aged patients in non-expansion states (n = 16,602) and expansion states (n = 15,921) before (years 2012-2013) and after (years 2015-2016) Medicaid expansion with adjusted difference-indifferences (DIDs) using multivariable linear regression. RESULTS: The DIDs of percentage of bladder cancer patients with Stage ≥ II disease (0.02%; 95% confidence interval [CI]-1.91 to 1.95%, p = 0.9), without insurance (-0.65%; 95% CI-1.71 to 0.41), and with metastatic disease at diagnosis (-0.07%; 95% CI-1.14 to 1.00, both p > 0.10) did not change following insurance expansion despite an increase in Medicaid coverage (6.03%; 95% CI 4.79 to 7.29, p < 0.01). Any treatment with either cystectomy, radiation or systemic therapy > 60 days after diagnosis of stage ≥ II disease did not change (DID 1.48%; 95% CI-3.29 to 6.25%, p = 0.50). On subgroup analysis of patients living in low-income regions, the rates of stage ≥ II disease, no insurance, metastatic disease, and time to treatment did not significantly change. CONCLUSION: Medicaid expansion was not associated with changes in advanced cancer stage at diagnosis or time to treatment in newly diagnosed bladder cancer patients.

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Comparison of Costs of Radical Cystectomy vs Trimodal Therapy for Patients With Localized Muscle-Invasive Bladder Cancer

Cited by 39 publications

References 37 publications

Incidence and outcome of salvage cystectomy after bladder sparing therapy for muscle invasive bladder cancer: a systematic review and meta-analysis

Incidence and outcome of salvage cystectomy after bladder sparing therapy for muscle invasive bladder cancer: a systematic review and meta-analysis

Trimodal Therapy vs. Radical Cystectomy for Muscle-Invasive Bladder Cancer: A Meta-Analysis

Bladder Cancer Following Medicaid Expansion: No Changes in the Diagnosis of Muscle-Invasive Disease and Time to Treatment

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