Treatment Patterns, Outcomes, and Costs Associated With Localized Upper Tract Urothelial Carcinoma

Abstract

Background Upper tract urothelial carcinoma (UTUC) is a heterogeneous disease that presents a clinical management challenge for the urologic surgeon. We assessed treatment patterns, costs, and survival outcomes among patients with non-metastatic UTUC. Methods We identified 4,114 patients diagnosed with non-metastatic UTUC from 2004-2013 in the Survival Epidemiology and End Results-Medicare linked population-based database. Patients were stratified into low- or high-risk disease groups. Median total costs from 30 days prior to diagnosis through 365 days after diagnosis were compared between groups. Overall and cancer-specific survival were evaluated using Cox proportional hazards regression. All statistical tests were 2-sided. Results After risk stratification, 1,027 (24.9%) and 3,087 (75.0%) patients were classified into low- vs high-risk UTUC groups. Most patients underwent at least one surgical intervention (95.1%); 68.4% underwent at least one endoscopic intervention. Patients diagnosed with high- vs low-risk UTUC were more likely to undergo nephroureterectomy (83.6% vs 72.0%, P<0.001); few patients with low-risk disease were exclusively managed endoscopically (16.9%). At 365 days after diagnosis, costs of care for high- vs low-risk UTUC was statistically significantly higher ($108,520 vs $91,233; median difference $16,704, 95% confidence interval [CI] = $11,619 to $21,778, P <0.001). Those with high-risk UTUC had worse cancer-specific and overall survival compared with patients with low-risk UTUC (cancer-specific survival hazard ratio = 4.14, 95% CI = 3.19 to 5.37; overall survival hazard ratio = 1.78, 95% CI = 1.62 to 1.96). Conclusions UTUC continues to be managed primarily with nephroureterectomy, regardless of risk stratification, and patients with high-risk UTUC have worse overall and cancer-specific survival. Substantial costs are associated with management of low- and high-risk UTUC, with the latter being more costly up to 1 year from diagnosis.

Potential for Urolithiasis-related Research Using the Novel Medicare-Litholink Database

“…10-13 It has also been applied to better understand outcomes and costs associated with different types of cancer testing and treatment. 14-16…”

“…[10][11][12][13] It has also been applied to better understand outcomes and costs associated with different types of cancer testing and treatment. [14][15][16] Another example is the Veterans Health Administration's (VHA's) Corporate Data Warehouse (CDW). Constructed in 2006, the CDW is a repository for patient-level data aggregated from across the VHA's national health delivery system.…”

Advances in chemoablation in upper tract urothelial carcinoma: overview of indications and treatment patterns

“…For low-risk UTUC (typically <2 cm, unifocal, low-grade, noninvasive), endoscopic laser ablation via ureteroscopy is recommended with the goal of obtaining complete tumor ablation while preserving renal function. However, a significant challenge with ablative methods is the high rate of local tumor recurrence that may eventually still lead to RNU ( 16 - 18 ). Some studies have quoted >50% risk of progression to RNU in patients with low-grade disease ( 19 ).…”

Learning from the past and present to change the future: Endoscopic management of upper urinary tract urothelial carcinoma

“…Over the last decades, radical nephroureterectomy (RNU) with bladder cuff excision remains the gold standard treatment 4 . On the other hand, endoscopic management (EM) is still less common; however, its use has gradually increased worldwide, which has been associated with reduced comorbidities and treatment costs 5–8 . Although EM offers comparable cancer‐specific survival (CSS) and overall survival to those of RNU, especially in cases of low‐risk tumors, a higher rate of upper urinary tract recurrence (up to 90.5%) is a serious drawback, thus requiring long‐term rigorous surveillance and repeated interventions (Table 1).…”