Division of Urology, Department of Surgical Oncology, University Health Network, Toronto, Ontario, Canada.
Cancer. 2009 Dec 1;115(23):5450-9. doi: 10.1002/cncr.24634.
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.
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.
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.
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.
虽然根治性膀胱切除术和膀胱内免疫治疗都是高危、T1、G3（T1G3）膀胱癌的初始治疗选择，但对于最佳策略仍存在争议。由于膀胱癌是每位患者治疗费用最高的恶性肿瘤，因此关于最佳治疗策略的决策应考虑成本。
创建了一个马尔可夫蒙特卡罗成本效益模型，以模拟一组患有新发高危、T1G3 膀胱癌的患者的结局。治疗选择包括立即行膀胱切除术和膀胱内卡介苗（BCG）保守治疗。基本病例为 60 岁男性。使用概率敏感性分析评估参数不确定性。情景分析用于探索按年龄和合并症分层的患者的 2 种策略。
立即行膀胱切除术和 BCG 治疗的质量调整生存时间分别为 9.46 个质量调整生命年（QALY）和 9.39 个 QALY。相应的每位患者终身贴现成本（2005 年加拿大元）分别为 37600 美元和 42400 美元。在每 QALY 支付意愿阈值为 50000 美元时，立即行膀胱切除术具有成本效益的概率为 67%。对于<60 岁的患者，立即行膀胱切除术是更有效的治疗方法，而对于>75 岁的患者，BCG 治疗是更有效的治疗方法。随着合并症的增加，在较低的年龄阈值下，BCG 治疗具有优势。
与 BCG 治疗相比，平均高危、T1G3 膀胱癌患者立即行根治性膀胱切除术可获得更好的健康结局和更低的成本。根据患者年龄和合并症制定治疗方案可能会提高生存率，并为医疗保健系统节省大量成本。
