How to reduce economic costs of bladder cancer?
Did you know that bladder cancer is the most expensive to treat, owing to the inefficient screening mechanisms? Dr J. Alfred Witjes, Department of Urology, Radboud University Nijmegen Medical Centre, says there is a lot to be improved in bladder cancer prevention, diagnosis and treatment. Though there are new developments in markers and therapy, he says better awareness of the economic burden would be a great step forward.
One of the first reports dealing with the economics of bladder cancer was published in 2003. (1) Botteman et al. performed a critical systematic review on the health economics of bladder cancer in developed countries. They also tried to identify opportunities or interventions to improve effectiveness of bladder cancer care and thereby reduce burden and costs. Although bladder cancer was identified as the fifth most expensive cancer in total medical care expenditures, per patient costs from diagnosis until death were highest of all cancers, ranging from 96-187 k$ in the US. A similar conclusion for the European situation is difficult to draw. Sievert et al. looked at the European economic aspects and identified 2 interesting aspects. (2). The first was the impact of the fact that bladder cancer has two different entities.
Non muscle-invasive bladder cancer (NMIBC) is treated with local resection (transurethral resection, TUR) of the tumor and subsequent intravesical instillations in the bladder to reduce recurrence rates of the tumor. In spite of this adjuvant treatment, although also depending on the risk category of the tumor, recurrences rates are as high as 61% within one year after TUR in the highest risk group. (3,4). Muscle invasive bladder cancer (MIBC), on the other hand, is treated after diagnosis by TUR with a combination of chemotherapy and surgery (removal of the bladder, radical cystectomy), which is clearly a totally different therapy and with a different outcome and impact on health related quality of life. Sievert et al. reported that two-thirds of bladder cancer costs were related to the TUR procedure for NMIBC.
A second interesting point is that costs and benefits in Europe differ significantly per country and health care system. TUR costs, for example, differed between €845 in France as compared to €2,231 in Germany. Radical cystectomy, on the other hand, ranged between €3,867 in the UK and €15,419 in Germany. The overall economic burden of bladder cancer in the European Union (EU) was addressed in 2016 by Leal et al. (5) For the year 2012, €4.9 billion was spent on bladder cancer in the EU. Health care (expenditures on primary, outpatient, emergency, and inpatient care, as well as medications) accounted for €2.9 billion (59%), which represented 5% of total health care cancer costs in the EU. Also taking into account estimation of other costs (23% for productivity losses and 18% for informal care), bladder cancer accounted for 3% of all EU cancer costs, representing an annual healthcare cost of €57 per 10 EU citizens. Again, however, costs varied >10 times between the country with the lowest cost, (Bulgaria, €8 for every 10 citizens), and highest cost (Luxembourg, €93). In summary, bladder cancer is a very costly disease, and costs differ significantly throughout Europe.
Reduction of costs
In 2003, Botteman et al. already identified several points where costs might be reduced. Screening of bladder cancer is not efficient, due to the low incidence rate, not even in high risk patients, and due to the low performance (urinary cytology), costs (cystoscopy) or absence (markers) of diagnostic tests. Especially good urinary markers might improve diagnosis and reduce burden and costs. Currently used therapies, both for NMIBC and MIBC are introduced decades ago, and have not really improved.
For NMIBC current therapies have not proved to be cost effective, since they have not consistently demonstrated survival benefits, nor have been able to prevent radical cystectomies. One small step forward has been the introduction of blue light cystoscopy, which has proven to be clinically effective and cost-effective for diagnosis and treatment of NMIBC, indeed reducing economic burden. (6)
Follow up of bladder cancer patients is not evidence based and predominantly expert opinion. Less frequent and less invasive monitoring will be cost effective, but is difficult to test in the clinical setting. Another potential cost saving strategy is centralization of for example radical surgery. Several reports have shown that the surgical volume is clearly related to morbidity (and costs) and mortality due to the disease and the procedure. Leow et al., for example, found that surgeons performing >7 radical cystectomies had a 45% lower odds ratio of major complications and a cost reduction of $1,690. (7) There was a striking difference in 90-day median hospital costs between patients without complications as compared to those with a major complication ($43 965 vs $24 341; P < 0.001). A clearly defined cut-off for a minimal yearly number of cystectomies, however, remains to be defined. Finally, even though there are guideline recommendations on treatment and follow up, these are not followed well throughout the urological community. (8)
In all there is still a lot to be improved in bladder cancer prevention, diagnosis and treatment, both for NMIBC and MIBC. There are new developments in markers and therapy, but better awareness of the economic burden of bladder cancer for patients, healthcare providers and policy makers would certainly be a step forward.
1. Botteman MF1, Pashos CL, Redaelli A, Laskin B, Hauser R. The health economics of bladder cancer: a comprehensive review of the published literature. Pharmacoeconomics. 2003;21:1315-30.
2. Sievert KD, Amend B, Nagele U, Schilling D, Bedke J, Horstmann M, Hennenlotter J, Kruck S, Stenzl A. Economic aspects of bladder cancer: what are the benefits and costs? World J Urol 2009;27:295–300
3. Sylvester RJ, van der Meijden AP, Oosterlinck W et al. Predicting recurrence and progression in individual patients with stage Ta T1 bladder cancer using EORTC risk tables: a combined analysis of 2596 patients from seven EORTC trials. Eur Urol 2006;49:466-477.
4. Fernandez-Gomez J, Madero R, Solsona E et al. Predicting nonmuscle invasive bladder cancer recurrence and progression in patients treated with bacillus Calmette-Guerin: the CUETO scoring model. J Urol 2009;182:2195-2203.
5. Leal J, Luengo-Fernandez R, Sullivan R, Witjes JA. Economic burden of bladder cancer across the European union. Eur Urol 2016;69:438-47
6. Witjes JA, Babjuk M, Gontero P, Jacqmin D, Karl A, Kruck S, Mariappan P, Palou Redorta J, Stenzl A, van Velthoven R, Zaak D. Clinical and cost effectiveness of hexaminolevulinate-guided blue-light cystoscopy: evidence review and updated expert recommendations. Eur Urol. 2014;66:863-71
7. Leow JJ, Reese S, Trinh QD, Bellmunt J, Chung BI, Kibel AS, Chang SL. Impact of surgeon volume on the morbidity and costs of radical cystectomy in the USA: a contemporary population-based analysis. BJUI int 2015;115:713-21
8. Chamie K, Saigal CS, Lai J, Hanley JM, Setodji CM, Konety BR, Litwin MS. Compliance with guidelines for patients with bladder cancer. Cancer 2011, 117:5392-401