Introduction:

Radical cystectomy (RC) is the historically accepted gold standard treatment for muscle invasive bladder cancer (MIBC), but trimodal therapy (TMT) has emerged as a valid therapeutic option. These two modalities however have not been directly compared. Therefore, we created a decision model assessing the effectiveness of TMT and RC using decision analysis methods.

Methods:

A two-dimensional Markov microsimulation model was constructed using TreeAge Pro to compare RC and TMT for patients with newly diagnosed MIBC (Figure 1). Model probabilities and utilities were derived from published literature. Our primary outcome was quality adjusted life expectancy (QALE). Secondary outcomes included crude life expectancy (LE), and bladder cancer recurrences in the TMT arm. Markov cycle length was dynamic to mimic actual clinical practice. The base case for our model was an adult patient with MIBC (pT2-4 N0 M0) considered appropriate for either RC or TMT. Individual level sampling was completed for age, gender, and reconstruction type (ileal conduit vs neobladder) assigned in the RC arm. 

Results:

TMT was the preferred modality with an estimated mean QALE of 7.49 (95%CI: 6.89-7.86) versus 7.41 (95%CI: 6.95-7.86) for RC but mean LE for patients treated with TMT was lower (10.21 years, 95%CI: 9.3-10.7) compared with RC (10.74 years, 95%CI: 10.0-11.4). A sensitivity analysis evaluating the impact of age showed that younger patients treated with RC had greater QALE and longer LE than those treated with TMT. However, inverse findings were observed for elderly patients (Table 1). Overall, 39.4% of patients in the TMT arm experienced a bladder recurrence with 27% undergoing a salvage cystectomy.

Conclusion:

Our study suggests that RC provides more unadjusted life years than TMT (0.53 years), but lower quality of life (-0.08). Differences in treatment preference were dependent on age. The younger patients are, the more likely they are to benefit from the oncological control derived from RC.

Funding: N/A