Increased Costs Associated With Excessive Surveillance and Treatment For Non–Muscle-Invasive Bladder Cancer

The annual median one-year cost of care for older adult patients with low-grade papillary Ta, noninvasive bladder cancer increased by 60%, or nearly $20,000, from 2004 to 2013, according to a recent population-based cohort study (JAMA Network Open. 2002;5(3):e223050; doi:10.1001/jamanetworkopen.2022.3050). 

The study team, which included several investigators from the Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, analyzed 13,054 patients between 66 and 90 years old who were selected from a Medicare database linked to the Surveillance, Epidemiology and End Results system. The team also analyzed Medicare claims data through the end of 2014. Their analysis was done from April 1 to October 6, 2021.

Their study was designed to describe current surveillance and treatment practices, clinical outcomes, and costs of care for this type of bladder cancer, as well as to determine factors associated with increases in the cost of care. 

The primary outcome of the study was the identification of patterns in population-level surveillance and treatment over time. Secondary outcomes included: (1) costs of care, (2) recurrence, defined as having another transurethral tumor resection more than 3 months after the index diagnosis of bladder cancer, and (3) progression, defined as having definitive treatment for bladder cancer. 

From their analysis, the research team discovered that the increase in cost to nearly $54,000 in 2013, up from less than $35,000 in 2004, resulted from substantial increases in the use of cystoscopy, upper urinary tract imaging, and urine cytologic testing during the 10-year study period. 

For example, rates of surveillance cystoscopy during the study period increased by 3 percentage points, from 79% to 82% (P = .007). By 2013, patients were receiving a median of 3 cystoscopies annually (interquartile range [IQR], 2 to 4 per yr). During the same period, rates of upper urinary tract imaging, especially computed tomography or magnetic resonance imaging, increased even more, by 17 percentage points, or from 30% to 47% (P < .001). By 2013, most patients were receiving a median of 2 imaging tests annually (IQR, 1 to 2 per yr). In addition, rates of urine cytologic testing or other urine biomarker assessments increased by 10 percentage points, or from 45% to 55% (P < .001).

From 2004 to 2008, a median of 4398 patients (55%) had ≤2 cystoscopies annually, vs a median of 2736 patients, or 54%, from 2009 to 2013 (P = .11). “Rates of adherence to current guidelines were similar over time,” wrote Stephen Williams, MD, MS, Division of Urology, Department of Surgery, University of Texas Medical Branch, Galveston, TX, and colleagues, adding that this suggests “overuse of all surveillance testing modalities”.

Regarding intravesicular treatment, 2250 patients (17%) received bacillus Calmette-Guérin, and 792 patients (6%), received chemotherapy. Regarding outcomes, 217 (nearly 2%) had a recurrence of disease, and 52 (<1%) had disease progression. By the end of the study period, median 1-year costs were nearly $23,000 greater in patients who had a recurrence of disease than in those who did not ($77,000 vs. $54,000, respectively).

In conclusion, the study authors wrote that, “despite low rates of disease recurrence and progression, rates of surveillance testing increased during the study period,” adding, “Efforts to improve adherence to current practice guidelines, with the focus on limiting overuse of surveillance testing and treatment, may mitigate associated increasing costs of care.”