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Daniel D. Joyce, MD, MS, discusses the economics of trimodal therapy in MIBC

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Ultimately, the take-home message for practicing urologists is to apply TMT judiciously, taking into account the patient's clinical profile, personal values, and financial situation.

In this interview, Daniel D. Joyce, MD, MS, assistant professor of urology at Vanderbilt University Medical Center in Nashville, Tennessee, discusses the economic and clinical considerations of using trimodal therapy (TMT) vs radical cystectomy for patients with muscle-invasive bladder cancer (MIBC). Although TMT—combining chemotherapy, radiation, and limited surgery—has been shown to preserve bladder function and potentially improve quality of life, the data on long-term outcomes remain limited and inconsistent. Some studies suggest TMT may offer better quality of life than cystectomy, whereas others show equivalence, highlighting the need for more comparative effectiveness research to guide shared decision-making.

A critical point raised is the importance of individualized patient assessment, especially regarding bladder function, baseline demographics, and comorbidities, to determine who might benefit most from TMT. Long-term toxicities associated with TMT—including cardiovascular issues, nephrotoxicity, neuropathy, and bowel or bladder dysfunction—must be weighed carefully, particularly in older patients, whose life expectancy and tolerance for adverse events may differ from those with cancers typically affecting younger populations.

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      The interview also emphasizes the broader implications of expanding TMT use, especially the economic burden it can impose on both the health care system and patients. Financial toxicity is a growing concern. Clinicians are urged to consider not only the clinical efficacy of TMT but also its economic feasibility and the patient’s financial resilience.

      Ultimately, the take-home message for practicing urologists is to apply TMT judiciously, taking into account the patient's clinical profile, personal values, and financial situation. Although the potential for bladder preservation is appealing, it may not always align with the best overall outcome for the patient or the health care system.

      REFERENCE

      1. Joyce DD, Wymer KM, Graves JA, et al. Cost-effectiveness of trimodal therapy and radical cystectomy for muscle-invasive bladder cancer. JAMA Netw Open. 2025;8(6):e2517056. doi:10.1001/jamanetworkopen.2025.17056

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