Abstract

Objectives

Bladder cancer incurs the highest lifetime treatment cost per patient among various cancers. Current guidelines endorse several cisplatin-based regimens as neoadjuvant chemotherapy. This cost-utility analysis aimed to compare 2 primary neoadjuvant chemotherapy regimens—dose-dense methotrexate, vinblastine, doxorubicin, and cisplatin (dd-MVAC) and gemcitabine and cisplatin (GC)—for patients with muscle-invasive bladder cancer, providing economic evidence to inform treatment guidelines in Iran.

Methods

A Markov decision model was constructed, incorporating 4 states: after radical cystectomy without recurrence, no radical cystectomy, recurrence, and death over a lifetime horizon. Clinical outcomes were derived from the VESPER (French Genito-Urinary Tumor Group and French Association of Urology V05) phase 3 randomized controlled trial, whereas costs were obtained from local Iranian data. The main result involved determining an incremental cost-effectiveness ratio within the simulated population, with a willingness-to-pay threshold of 1656 USD (equivalent to Iran’s gross domestic product per capita in 2023). Costs and benefits were discounted at 5.8% per annum, and probabilistic and univariate deterministic sensitivity analyses were conducted.

Results

From the perspective of the Iranian healthcare payer, 6 cycles of dd-MVAC yielded 0.02 greater quality-adjusted life-years compared with 4 cycles of GC, resulting in a cost saving of 1 173 491 USD and an incremental cost-effectiveness ratio of −78 708 870. Consequently, dd-MVAC emerged as the dominant option over a lifetime horizon (23 years). The model proved most sensitive to variations in recurrence and toxicity probabilities during treatment.

Conclusions

Based on this study’s results, dd-MVAC represents a cost-saving treatment regimen per patient in the Iranian health system compared with GC, with superior utility.