Routine Perioperative Chemotherapy Instillation With Initial Transurethral Resection: A Cross Examination Of Economic Benefits

Main Category: Urology / Nephrology
Also Included In: Cancer / Oncology
Article Date: 29 Jun 2008 - 0:00 PDT

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ORLANDO, FL (UroToday.com) - Indisputable level-one evidence has demonstrated decreased recurrence rates of low-grade (LG) bladder tumors when initial bladder tumor resection is followed by chemotherapeutic perioperative instillation (PI). A meta-analysis found 8.5 patients to be the number needed to treat (NNT) to prevent one bladder tumor recurrence, however patients with no tumor were excluded from the analysis thus underestimating the true NNT.

In addition, it has been suggested that routine PI would be economically prudent, but no calculation of actual treatment costs was presented to validate this claim. The authors analyzed the economics of PI with the goal of determining the NNT, and determining the actual costs and alternative management options.

The reimbursements made by Medicare for PI, and those for tumor management in different settings (i.e. hospital inpatient, ambulatory surgery center (ASC), physicians office) at the Cleveland Clinic were examined. 9.6 patients need to be treated (NNT) to prevent one tumor recurrence. With procedural and pharmacy costs, PI adds > $201.39 to the cost of initial transurethral resection (TUR). The cost of treating 9.6 patients with PI adds > $1933 to the cost of the initial TURs. This is indeed less than the cost of managing one recurrence with hospital inpatient TUR ($4680.58), suggesting an economic benefit to routine PI.

However, the cost to treat 9.6 patients with PI is greater than the cost of outpatient TUR in the hospital ($1813.53), office fulguration ($1251.45), or TUR in the ASC ($680.43). In our model, if > 69% of all recurrences were managed as outpatients with TUR in the ASC rather than inpatient hospital TUR, then the economic benefit of PI would be fully offset.

The authors conclude that although PI decreases low grade bladder tumor recurrence, our model suggests that the economic impact of PI is limited in the USA. For PI to be economically sound, treatment of recurrent non-invasive bladder cancer should be outside the hospital and either in a surgery center or physician's office.

Presented by Pravin K Rao, MD, J Stephen Jones, MD, at the Annual Meeting of the American Urological Association (AUA) - May 17 - 22, 2008. Orange County Convention Center - Orlando, Florida, USA.

Reported by UroToday.com Contributing Editor David P. Wood, MD

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