University of Toronto
Molecular subtyping to stratify the treatment of muscle-invasive bladder cancer: A cost effectiveness analysis
Diana E. Magee1,3, Douglas C. Cheung1,3, Beate Sander2,3, Girish S. Kulkarni1,3.
1Division of Urology, Department of Surgery, University Health Network, University of Toronto, Toronto, ON, Canada; 2Toronto Health Economics and Technology Assessment Collaborative (THETA), University of Toronto, Toronto, ON, Canada; 3Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
Introduction: The gold standard treatment for muscle invasive bladder cancer (MIBC) is neoadjuvant chemotherapy (NAC) followed by radical cystectomy. However, response to NAC is unpredictable. Molecular subtypes allow for an improved ability to select a tailored treatment course. Our study aims to assess the cost-effectiveness of molecular subtyping in the management of MIBC.
Methods: A two-dimensional Markov microsimulation model was developed using TreeAge Pro comparing three strategies: NAC at current usage rates (36%), universal NAC usage, and molecular subtype-directed care. Model probabilities and utilities were derived from the published literature. Cost of each phase of care was obtained from primary data and the Canadian Institute for Health Information patient cost estimator. The primary outcomes were quality-adjusted life years (QALYs), cost, overall survival (OS) and the incremental cost-effectiveness ratio (ICER).
Results: The predicted QALYs were 8.34, 8.73, and 9.14 with costs of $62,478, $76,962, and $62,579 for NAC at current usage rates, universal NAC usage, and subtype-directed care, respectively. OS at 10 years was 39.2%, 40.8% and 42.8% for NAC at current usage rates, universal NAC usage, and subtype-directed care, respectively. When comparing subtype-directed care to current rates of NAC usage the ICER was $127/QALY. Subtype-directed care dominated universal NAC usage.
Conclusion: We demonstrated that in patients with MIBC a molecular subtype directed approach to the administration of NAC can result in improved overall survival, greater QALYs and be cost-effective within a single payer healthcare system. A push to the universal use of NAC will result in improved survival compared with what our current rates of use achieve but is likely not the best approach considering the drawbacks of chemotherapy including toxicity and unequal response. This model is built upon the available literature and requires validation prior to clinical implementation.
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