Muscle-invasive bladder cancer management
The gold-standard treatment for localized muscle-invasive bladder cancer (MIBC) is a radical cystectomy with urinary diversion, with neoadjuvant chemotherapy if the patient is eligible. However, there are multiple areas in the treatment and management of MIBC where patients are not receiving guideline-concordant care. Only about 20% of patients with MIBC undergo radical cystectomy,35-37 with only about 13% of patients undergoing neoadjuvant chemotherapy.38
There also appears to be a significant barrier to accessing available providers who would perform a cystectomy, as patients who traveled long distances had lower odds of undergoing a radical cystectomy.37 Patients who underwent a radical cystectomy had improved overall and disease-specific survival compared to those who underwent other alternative treatments.37 Improved compliance with guidelines for the management of MIBC can improve the health-related outcomes associated with bladder cancer.
Minimally invasive approaches to radical cystectomy were developed in the hopes of reducing the morbidity associated with radical cystectomy. Three randomized controlled trials39-41 and three systematic meta-analyses42-44 have compared the outcomes of the standard open cystectomy to the robot-assisted approach, with the final findings of the multicenter RAZOR study yet to be published. In general, these randomized controlled trials and meta-analyses have found that the robot-assisted cystectomy was associated with decreased blood loss but longer operative times. Associations with length of stay and postoperative complications differed with each study and cohort.
Cost identification analysis was performed comparing the costs of robot-assisted cystectomy with open cystectomy in three separate studies of large-volume centers (about 200-300 cases per year).45-47 In two of these analyses, robot-assisted cystectomy was associated with a shorter length of stay than open cystectomy, and also conferred a significant decrease in hospitalization costs by 60%-70% and overall costs by 19%-38%.46,47 The direct equipment costs were higher with robot-assisted cystectomy in these studies of large-volume centers, but overall offset by the improvement in length of stay and complications. However, it is important to remember that these studies are of high-volume centers with expertise in robotic cystectomy, as both studies had operative times that were equivalent or faster than the open cystectomies.
Two population-based analyses confirmed the findings that robot-assisted cystectomies add about $4,000 per case compared to open, primarily because of increased supply costs.48,49 However, the cost difference with robotic cystectomy would disappear in high-volume centers (>19 cases per year) or when performed by high-volume surgeons (>7 cases per year).49 Robot-assisted cystectomies are consistently associated with higher direct costs than open procedures with more equipment purchases, maintenance, and disposable instruments. However, ownership of a robotic platform can increase utilization for other urologic, surgical, or gynecologic procedures that can then marginalize the additional equipment costs.
In high-volume facilities, there can be potential cost savings associated with the robotic procedure if the length of stay and complication rates can be significantly decreased. Future studies that analyze the cost per quality-adjusted life year will help clarify the potential value for a robot-assisted approach.
Postoperative length of stay is an important factor in the patient’s quality of life and costs of bladder cancer care. Enhanced recovery after surgery (ERAS) protocols aim to standardize perioperative care and reduce variation. Although there is some variation in ERAS protocols between institutions, different randomized trials and meta-analyses have found that overall, ERAS protocols are associated with decreased overall complication rates, length of stay, and a faster return of bowel function.50 A cost-effectiveness analysis at a high-volume tertiary center found that the implementation of an ERAS protocol produced an overall average 30-day cost savings of about $4,500 per procedure.51
Postoperative ileus is the most common complication that can affect length of stay. Alvimopan (Entereg) is a mu-opioid receptor antagonist that has been shown to significantly improve time to return of bowel function after cystectomy, decrease the postoperative ileus rate by more than 50%, and decrease the postoperative length of stay.52 The published wholesale price for alvimopan is $62.50, with maximum cost of about $937.50 for 15 doses.53 In one cost-consequence analysis, utilization of alvimopan was associated with a cost reduction of more than $2,300 per patient.54 Most of the cost savings resulted from a shorter length of stay (by almost 3 days), decreased utilization of gastrointestinal medications, and decreased parenteral nutrition use. The routine use of ERAS protocols with alvimopan utilization can significantly decrease postoperative length of stay and complication rates associated with cystectomy and thereby significantly decrease the overall costs of bladder cancer management.
There has been an increasing emphasis on improving the value of health care by improving the quality or outcomes of care while decreasing the costs. The management and treatment of bladder cancer is costly, but certain areas of improvement can have a dramatic impact on outcomes and costs. Cost-saving measures, such as the use of front-line renal ultrasound with cystoscopy instead of a CT scan, can help decrease costs while not compromising outcomes. Quality improvement measures, such as improving compliance with guideline-concordant care in the management of NMIBC and MIBC can decrease recurrence and progression rates, improve outcomes, and prevent unnecessary costs.
Finally, the implementation of newer processes such as blue-light cystoscopy, ERAS protocols, and alvimopan can significantly decrease costs and improve the health outcomes of patients undergoing a cystectomy. Future studies that focus on cost-effectiveness relative to quality of life after cystectomy will be essential to determine other potential areas of improvement.