427 EVALUATING COST AND QUALITY OF LIFE IN NON-MUSCLE INVASIVE BLADDER CANCER

Abstract

INTRODUCTION AND OBJECTIVES: Bladder cancer is the most expensive cancer to treat on a per-patient and per-death basis in the Medicare system, with an estimated financial burden of $3.98 billion/year. The majority of patients initially present with non-muscle invasive bladder cancer (NMIBC), requiring primary treatment and strict surveillance protocols. Previous studies have explored cost-effective strategies that maximize survival, but not quality of life (QOL). Our aim was to evaluate the cost of NMIBC in the context of quality of life. METHODS: We reviewed our IRB-approved Columbia University Urologic Oncology Database for patients with an initial diagnosis of NMIBC from 2004-2012. One hundred patients were randomly selected, and the costs of all diagnostics, intravesical therapy (IVT), surgeries, complications, and imaging were tallied utilizing internal billing and national Medicare estimates. QOL was assessed using utility estimates (patient-rated QOL for each possible health state), and the number of quality-adjusted life years (QALYs) was calculated by multiplying the utilities by the total time spent in that utility state and summing these values. Dividing the total average cost by the total average number of QALYs gained per patient gives the cost required to add one QALY. Patients were stratified into four treatment groups: 1) IVT cystectomy (RC); 2) IVT maintenance RC; 3) IVT maintenance; and 4) immediate RC. RESULTS: The patient cohort was 73% male, median age at diagnosis was 67 years (38-90) and median follow-up was 44 months (1.5-103.5). Figure 1 demonstrates that IVT maintenance adds the most QALYs and is the most cost-effective for overall survival and quality of life, requiring $8862 to add one QALY to one patient’s life. The other three treatment strategies were approximately equal, with IVT maintenance delayed RC being the least cost-effective, at $21158/QALY. CONCLUSIONS: Treating NMIBC with IVT maintenance adds the most QALYs compared with treatments involving cystectomy. Therefore, delaying cystectomy with additional maintenance therapy may be the most cost-effective option (if medically advisable), since it has the potential to add QALY at low cost, and late RC costs no more than early RC to add the same QALY.