Purpose: Bladder cancer is a common disease, with greater than 70,000 new cases per year and over 600,000 prevalent cases in the US alone. Three-fourths of incident cases are non-muscle-invasive (<T2) and approximately half of all incident bladder tumors are low grade, noninvasive (LGTa), with moderate recurrence risk and rare (<5% at five years) progression to the potentially lethal phenotype of muscle-invasive (T2) disease. Contemporary epidemiological data suggest the incidence of this lowest-risk subgroup is disproportionately increasing with the aging of the population. Explicit risk stratification and lower intensity follow-up for low risk disease are salient differences in the European Association of Urology (EAU) practice guidelines compared to those of the American Urological Association (AUA). Currently, the AUA does not explicitly recommend a risk stratified approach, essentially recommending uniformly intense surveillance for all patients with superficial disease.
Method: Medicare charges for each aspect of the surveillance protocol were used to estimate per-patient and total cohort direct medical costs. Annual per-protocol costs were calculated according to the AUA and EAU guidelines and extrapolated to overall 5 year costs per-patient as well as total surveillance costs for a cohort of LGTa patients diagnosed yearly.
Result: Per EAU protocol, the average cost per patient yearly and at five years for surveillance of LGTa was $2,228, and $6,684 respectively. Per AUA guidelines, average one and five-year cost per patient is $4,456 and $14,482 respectively. For the total population of LGTa patients diagnosed in one year, these differences result in total costs at 5 years of $235,711,260 for the EAU protocol versus $510,707,730 for the AUA. Total yearly surveillance cost savings for low grade Ta disease per patient and nationally of $7,798 and $274,996,470 respectively would be obtained by adopting risk-stratified surveillance for one year of incident cases in the lowest-risk stratum.
Conclusion: With an aging population and heightened pressure to scrutinize the value of medical care, explicitly risk-stratifying patients could yield greater than 50% cost savings during surveillance for LGTa bladder cancer at one and five years. Given the exceedingly low risk of progression to potentially lethal disease among patients with incident LGTa disease, these data motivate a critical reevaluation of the cost effectiveness of the management of low risk disease
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