(UroToday.com) The 2024 American Society of Clinical Oncology Genitourinary (ASCO GU) cancers symposium held in San Francisco, CA was host to a urothelial carcinoma poster session. Dr. Stephen Williams presented the results of a real-world analysis of the economic burden of radical cystectomy and trimodal therapy for bladder cancer in the United States of America.
Bladder cancer is exponentially deadly once it invades the muscularis propria with one of the highest per-patient treatment costs among all malignancies. Radical cystectomy (RC) and trimodal therapy (TMT) are recommended treatment options for muscle-invasive bladder cancer. However, there is limited research regarding the economic impacts of the various treatment types for bladder cancer. The study objective was thus to describe patient/treatment characteristics and short- and long-term costs/healthcare utilization associated with RC and TMT.
Patients with bladder cancer undergoing RC or TMT were identified using the Optum Clinformatics® DataMart claims database from October 2015 to April 2023. For the RC cohort, the index date was the bladder cancer diagnosis date that was within 6 months prior and closest to the RC. Receipt of RC was determined using CPT and ICD-10 codes for bladder removal and neobladder, or a code for bladder removal and at least one code for colonic diversion, ileal conduit, cutaneous ureterostomy, or neobladder
For the TMT cohort, the index date was the bladder cancer diagnosis claim within 6 months prior and closest to the first transurethral resection of bladder tumor (TURBT). TMT was ascertained using CPT codes identifying at least one claim of each: TURBT, chemotherapy, and radiotherapy.
The study inclusion criteria were as follows:
- Adult patients with two separate diagnoses of bladder cancer on separate days within 6 months during the identification period and received either RC or TMT treatment
- 6 months of continuous enrollment prior to the index visit and 12 months of continuous enrollment following the index visit, unless the patient died within 12 months after the diagnosis date
The exclusion criteria were patients meeting any of the following:
- Breastfeeding or pregnant patients
- Had a non-incident case of bladder cancer
- Did not receive RC or TMT treatment
- Had participated in a clinical trial
- Had a non-bladder malignancy diagnosis
- Had a secondary malignant neoplasm of the bladder
- Had undergone nephroureterectomy without RC within +/- 1 day of procedure
- 65 years of age or older and covered by both Medicare and a commercial insurance or Medicaid
Costs and healthcare utilization (e.g., inpatient, outpatient, emergency, pharmacy) were evaluated using medical claims data up to five years of follow-up or the end of available patient records. All healthcare costs were adjusted to 2022 US dollars according to the medical care and prescription drug component of the Consumer Price Index. Neoadjuvant chemotherapy in RC patients was determined as having ≥2 chemotherapy claims two weeks apart from each other prior to RC. Radiotherapy fractions in the TMT cohort were assessed by counting the number of unique CPT codes for radiation delivery using a window from the start of radiation delivery until 90 days thereafter.
The median ages of the RC (N = 839) and TMT (N = 484) cohorts were 71 (IQR: 66-76) and 75 (IQR: 69-81) years, respectively; 26.2% were female in both the RC and TMT cohorts. The mean National Cancer Institute (NCI) comorbidity index was similar for the two cohorts with 0.5 in the RC cohort and 0.52 in the TMT cohort. Medicare was the largest payer type among RC and TMT patients (77% and 87%, respectively) with a lower proportion of patients having commercial coverage (23% and 13%). Prior to RC, approximately 25% of patients received neoadjuvant chemotherapy. For patients receiving TMT, the median radiotherapy fractions delivered was 36, and 8.1% underwent salvage RC.
With regards to overall costs, the median cumulative costs in the RC cohort were $70,671 at 3 months, $103,579 at 1 year, and $211,671 by 5 years. Conversely, for the TMT cohort, median costs were $34,612, $116,259, and $274,462, respectively.
For the RC cohort, the majority of inpatient costs were derived from facility costs (mean; 0-3 months: $57,328; 48-60 months: $10,035) followed by surgery services (0-3 months: $5,525; 48-60 months: $399)
For the TMT cohort, the leading driver of inpatient costs were facility costs (0-3 months: $7,701: 48-60 months: $14,398) followed by professional inpatient services (0-3 months: $631; 48-60 months: $751). The largest contributor to outpatient costs in the RC cohort were drugs administered (0-3 months: $1,473; 48-60 months: $3,170) followed by radiology facility costs (0-3 months: $1,257: 48-60 months: $2,038). Drugs administered were the largest driver of outpatient costs in the TMT cohort (0-3 months: $3,995; 48-60 months: $21,540) followed by radiology facility costs (0-3 months: $7,405; 48-60 months: $5,665).
With respect to healthcare utilization, outpatient visits were the most common for both the RC and TMT cohorts; the median outpatient visits rose from 8 in the RC cohort at 3 months to 92 at 5 years and from 15 in the TMT cohort at 3 months to 158 at 5 years.
Pharmacy claims were numerically similar between RC and TMT cohorts at 3 months with a median of 8 in the RC cohort and 8 in the TMT cohort; however, pharmacy claims had risen to numerically higher levels in the TMT cohort at 5 years with a median of 114, compared to 78 in the RC cohort.
Notable limitations of this study included:
- Using a claims database and all limitations regarding research conducted with secondary data applying to this study.
- Additionally, components of the patient journey that were not captured in the database were not included in the analysis (eg, encounters not serviced by Optum were not included in the analysis)
Dr. Williams concluded that:
- The burden of RC- or TMT-treated bladder cancer remains high, suggesting key targets for cost containment to optimize value-based care
- Healthcare costs were predominantly related to outpatient services for TMT patients, while RC patients had high initial inpatient costs followed by continued contribution of outpatient costs over time
- Future research should evaluate the cost/health care utilization implications of guideline-recommended treatments, such as neoadjuvant chemotherapy followed by RC and TMT with advised chemotherapy type/duration
Presented by: Stephen B. Williams, MD, MBA, MS, FACS, FACHE, Professor (tenured) and Chief of the Division of Urology, University of Texas Medical Branch, Galveston, TX
Written by: Rashid Sayyid, MD, MSc – Society of Urologic Oncology (SUO) Clinical Fellow at The University of Toronto, @rksayyid on Twitter during the 2024 American Society of Clinical Oncology Genitourinary (ASCO GU) Cancers Symposium, San Francisco, CA, January 25th – January 27th, 2024