
Trevor Royce, MD, MS, MPH
Brigham and Women's Hospital
Genitourinary Cancer
PV QA 1 - Poster Viewing Q&A 1
Trevor Royce, MD, MS, MPH
Brigham and Women's Hospital
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 |
Brigham and Women's Hospital
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