title: Cost-effectiveness analysis of immediate radical cystectomy versus intravesical Bacillus Calmette-Guerin therapy for high-risk, high-grade (T1G3) bladder cancer.
abstract: BACKGROUND
  Although both radical cystectomy and intravesical immunotherapy are initial treatment options for high-risk, T1, grade 3 (T1G3) bladder cancer, controversy regarding the optimal strategy persists. Because bladder cancer is the most expensive malignancy to treat per patient, decisions regarding the optimal treatment strategy should consider costs.
  
  
  METHODS
  A Markov Monte-Carlo cost-effectiveness model was created to simulate the outcomes of a cohort of patients with incident, high-risk, T1G3 bladder cancer. Treatment options included immediate cystectomy and conservative therapy with intravesical Bacillus Calmette-Guerin (BCG). The base case was a man aged 60 years. Parameter uncertainty was assessed with probabilistic sensitivity analyses. Scenario analyses were used to explore the 2 strategies among patients stratified by age and comorbidity.
  
  
  RESULTS
  The quality-adjusted survival with immediate cystectomy and BCG therapy was 9.46 quality-adjusted life years (QALYs) and 9.39 QALYs, respectively. The corresponding mean per-patient discounted lifetime costs (in 2005 Canadian dollars) were $37,600 and $42,400, respectively. At a willingness-to-pay threshold of $50,000 per QALY, the probability that immediate cystectomy was cost-effective was 67%. Immediate cystectomy was the dominant (more effective and less expensive) therapy for patients aged <60 years, whereas BCG therapy was dominant for patients aged >75 years. With increasing comorbidity, BCG therapy was dominant at lower age thresholds.
  
  
  CONCLUSIONS
  Compared with BCG therapy, immediate radical cystectomy for average patients with high-risk, T1G3 bladder cancer yielded better health outcomes and lower costs. Tailoring therapy based on patient age and comorbidity may increase survival while yielding significant cost-savings for the healthcare system.
authors.affiliation: Division of Urology, Department of Surgical Oncology, University Health Network, Toronto, Ontario, Canada. girish1975@gmail.com
authors.forename: Girish S
authors.initials: GS
authors.lastname: Kulkarni
authors.forename: Shabbir M H
authors.initials: SM
authors.lastname: Alibhai
authors.forename: Antonio
authors.initials: A
authors.lastname: Finelli
authors.forename: Neil E
authors.initials: NE
authors.lastname: Fleshner
authors.forename: Michael A S
authors.initials: MA
authors.lastname: Jewett
authors.forename: Steven R
authors.initials: SR
authors.lastname: Lopushinsky
authors.forename: Ahmed M
authors.initials: AM
authors.lastname: Bayoumi
mesh_terms: D001500:BCG Vaccine / Q000191:economics* / Q000627:therapeutic use*; D015897:Comorbidity; D003362:Cost-Benefit Analysis; D015653:Cystectomy / Q000191:economics*; D006801:Humans; D008297:Male; D008390:Markov Chains; D008875:Middle Aged; D011336:Probability; D011379:Prognosis; D019057:Quality-Adjusted Life Years; D012680:Sensitivity and Specificity; D015996:Survival Rate; D001749:Urinary Bladder Neoplasms / Q000188:drug therapy* / Q000191:economics / Q000601:surgery*
chemical_list: D001500:BCG Vaccine