Genitourinary Cancer

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SU_21_2212 - Comparative Effectiveness of Bladder-preserving Tri-modality Therapy Versus Radical Cystectomy for Muscle-Invasive Bladder Cancer

Sunday, October 21
1:15 PM - 2:45 PM
Location: Innovation Hub, Exhibit Hall 3

Comparative Effectiveness of Bladder-preserving Tri-modality Therapy Versus Radical Cystectomy for Muscle-Invasive Bladder Cancer
T. J. Royce1,2, A. S. Feldman3, M. Mossanen3, J. C. Yang4, W. U. Shipley5, P. V. Pandharipande6,7, and J. A. Efstathiou5; 1Harvard Radiation Oncology Program, Boston, MA, 2Massachusetts General Hospital, Boston, MA, 3Department of Urology, Massachusetts General Hospital, Boston, MA, 4Memorial Sloan Kettering Cancer Center, New York, NY, 5Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 6Department of Radiology Massachusetts General Hospital, Boston, MA, 7Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA

Purpose/Objective(s): Radical cystectomy (RC) has historically been considered the standard of care for muscle-invasive bladder cancer (MIBC). An alternative is trimodality therapy (TMT), a bladder-sparing approach that often achieves preservation of the native bladder. There are limited randomized data comparing these guideline-recommended approaches but, in appropriately selected patients, both are thought to have similar survival outcomes with different morbidity profiles. We therefore aim to compare the effectiveness of TMT and RC using decision-analytic modeling.

Materials/Methods: We simulated the lifetime outcomes in 67-year-old patients with American Joint Committee on Cancer clinical Stage T2-T4aN0M0 MIBC. Competing treatment strategies were tri-modality therapy versus radical cystectomy +/- neoadjuvant chemotherapy. We used a Markov model to determine the incremental effectiveness in quality-adjusted life years (QALYs). Model probabilities and utilities were extracted from the literature. The effectiveness of each strategy was reported and sensitivity analyses were performed.

Results: For all MIBC patients, TMT was the most effective strategy with an incremental gain of 1.13 QALYs over RC (8.37 versus 7.24 QALYs, respectively). One-way sensitivity analyses demonstrated the model was most sensitive to the quality of life (QoL) parameters (i.e. the utilities) for RC and TMT; TMT was more effective than RC irrespective of the RC utility (the 95% confidence interval of the RC parameter demonstrated an incremental gain with TMT from 0.01to 4.77 QALYs). The model was relatively less sensitive to the probability of death for either strategy. Probabilistic sensitivity analysis demonstrated that TMT was more effective than RC for 75% of model iterations. When limiting the RC strategy to those with favorable, low-risk (clinical T2) MIBC, TMT remained the most effective strategy with an incremental gain of 0.61 QALYs over RC.

Conclusion: Treatment of MIBC with organ-sparing TMT in appropriately selected patients may result in a gain of QALYs relative to RC. Further prospective investigation into the QoL implications of these treatment modalities is warranted. Table: Effectiveness of RC compared to TMT. Abbreviations: EV, expected value; LY, life years; IV, incremental value; QALY, quality-adjusted life years.
Strategy EV (LYs) IV EV (QALYs) IV
TMT 9.51 - 8.37 -
RC, all patients 8.89 0.62 7.24 1.13
RC, low-risk cohort 9.34 0.17 7.76 0.61

Author Disclosure: T.J. Royce: None. A.S. Feldman: Consultant; Olympus America, INC. M. Mossanen: None. J.C. Yang: Senior Committee Member; ARRO. W.U. Shipley: Stock; Pfizer. Co-Chair of RTOG FOUNDATION; also Co-Chair of GU D; RTOG. P.V. Pandharipande: None. J.A. Efstathiou: Joint Safety Review Committee; Bayer Healthcare. Consultant; Blue Earth Diagnostics. Advisory Board; EMD Serona/Pfizer, Genentech. GU Track Past-Chair; ASTRO. Board of Directors; Massachusetts Prostate Cancer Coalition. Co-chair; NCI, NRG Oncology. Member; NRG Oncology.

Trevor Royce, MD, MS, MPH

Brigham and Women's Hospital

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