Cost-Effectiveness of Maintenance BCG for Intermediate and High Risk Non-Muscle Invasive Bladder Cancer
Menée aux Etats-Unis à l'aide d'un modèle mathématique intégrant des données de la littérature scientifique, cette étude estime le rapport coût-efficacité d'un traitement d'entretien par le bacille de Calmette-Guérin chez les patients âgés d'au moins 65 ans et atteints d'un cancer non invasif de la vessie à risque intermédiaire ou élevé de récidive
Introduction: While guidelines support the use of maintenance BCG(mBCG) for patients with intermediate- and high-risk non-muscle invasive bladder cancer(NMIBC), in an era of BCG shortage we explored the cost-effectiveness of mBCG.
Methods: A Markov model compared the cost-effectiveness of mBCG to surveillance after induction BCG for intermediate/high risk NMIBC from a US Medicare perspective. Five-year oncologic outcomes, toxicity rates, and utility values were extracted from the literature. Univariable and multivariable sensitivity analyses were conducted. A willingness-to-pay threshold of $100,000 per quality adjusted life year (QALY) was considered cost-effective.
Results: At 5 years, mean costs per patient were $14,858 and $13,973 for mBCG and surveillance respectively, with QALYs of 4.046 for both, making surveillance the dominant strategy. On sensitivity analysis, full dose and 1/3 rd dose mBCG became cost-effective if the absolute reduction in five-year progression was >2.1% and >0.76%, respectively. On further sensitivity analysis, full dose mBCG and 1/3 rd dose mBCG became cost-effective when mBCG toxicity equaled surveillance toxicity. In multivariable sensitivity analyses using 100,000 Monte-Carlo microsimulations, full dose and 1/3 rd dose mBCG were cost-effective in 17% and 39% of microsimulations, respectively.
Conclusions: Neither full dose mBCG nor 1/3 rd dose mBCG appears cost-effective for the entire population of intermediate/high risk NMIBC. These data support prioritizing mBCG for the subset of high risk NMIBC patients most likely to experience progression, in particular those who tolerated induction BCG well. Overall, our findings support the AUA policy statement to allocate BCG for induction rather than maintenance therapy during times of BCG shortage.
Journal of Urology , résumé, 2019