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Downstream Costs of Routine Single-Instillation Gemcitabine vs Mitomycin C After Resection of Low-Risk Non-Muscle Invasive Bladder Cancer
Jonathan J. Song, BS1, Winston Tan, BS1, Carissa Chu, MD2, Mark Preston, MD, MPH3, Daniel A. Wollin, MD, MS3.
1Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA, 2University of California San Francisco, San Francisco, CA, USA, 3Brigham and Women's Hospital, Boston, MA, USA.
BACKGROUND: Guidelines support single-instillation gemcitabine after transurethral resection (TURBT) of low-risk non-muscle invasive bladder cancer, but data from randomized control trials are mixed, and uptake is limited with significant socioeconomic disparities. Mitomycin C (MMC) is also endorsed for equal oncologic benefit, but greater costs and adverse effects raise concern. We assessed initial and downstream costs associated with gemcitabine and MMC after low-risk TURBT.
METHODS: We created a decision-analysis Markov model from the provider perspective. Outcome rates and costs were determined from weighted-average estimates from published literature. Four health states were modeled: no evidence of disease (NED), recurrence, progression to cystectomy, and disease-specific mortality. We simulated a yearly US cohort (n=15,000) over a time horizon of 5 years and reported incremental costs between different gemcitabine-use strategies, MMC-use strategies, and no intervention.
RESULTS: In patients undergoing initial TURBT with confirmed low-risk disease, routine gemcitabine saved $1,124 per patient compared to no intervention while MMC saved $1,238. If given to all patients with suspected low-risk disease with a rate of confirmed low-risk disease of 57.4%, routine gemcitabine saved $1,084 per patient compared to no intervention while MMC saved $452. Gemcitabine was well-tolerated as rate of grade 1-2 adverse events was 33.5% (assumed to incur $100) and grade 3 adverse events was 1.4% (assumed to incur $1000), resulting in $47.69 of added cost per patient. Mitomycin C was also well-tolerated, with grade 1-2 adverse events (45.5%) and grade 3 adverse events (3.4%) resulting in $79.21 of added cost per patient.
CONCLUSIONS: Gemcitabine and MMC resulted in modest cost-savings after low-risk TURBT, but gemcitabine cost-savings were robust even in the absence of confirmed low-risk disease. Costs associated with adverse effects were minimal. Given disappointing uptake and socioeconomic disparities in chemotherapy after low-risk TURBT, our results support the need for quality improvement efforts and systems-level reform.
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