Evaluating the Cost-Utility of Intravesical Bacillus Calmette-Guérin Versus Radical Cystectomy in Patients With High-Risk Non-Muscle-Invasive Bladder Cancer in the UK

OBJECTIVES: Approximately two-thirds of bladder cancer (BC) cases present as non-muscle-invasive BC (NMIBC). In patients classified as having high-risk NMIBC under the European Association of Urology risk stratification system, recommended treatments are either intravesical Bacillus Calmette-Guérin (BCG) or radical cystectomy (RC). The aim of the present study was to evaluate the cost-effectiveness of BCG versus RC in patients with high-risk NMIBC from the perspective of a UK healthcare payer.

METHODS: A six-state Markov model was developed covering controlled disease, post-cystectomy, post-first recurrence, post-chemohyperthermia, metastatic disease, and dead. The model also incorporated three “tunnel” states: first recurrence, second recurrence, and progression to muscle-invasive BC. Drug costs were obtained from the British National Formulary while costs of RC were obtained from the National Tariff Payment System. Utilities and dis-utilities were obtained primarily from the BOXIT trial. Analyses were run over a 30-year time horizon and future costs and effects were discounted at 3.5% per annum. One-way and probabilistic sensitivity analyses were performed.

RESULTS: The base case analysis comparing BCG with RC showed that BCG would result in an increase in life expectancy of 0.29 life years (LYs) versus RC from 8.48 to 8.77 LYs. BCG also resulted in an increase of 0.43 quality-adjusted life years (QALYs) versus RC, from 6.22 to 6.65 QALYs. Patients treated with BCG incurred lower costs than those treated with RC, with costs decreasing from GBP 100,521 to GBP 94,613 over patient lifetimes. Cost savings were driven by the lower cost of BCG versus RC, reductions in costs of chemotherapy for metastatic disease, and neoadjuvant chemotherapy. BCG was therefore the dominant intervention, improving quality-adjusted life expectancy and reducing costs versus RC.

CONCLUSIONS: Treating high-risk NMIBC patients with intravesical BCG was found to improve quality-adjusted life expectancy and reduce costs from the healthcare payer perspective in the UK.