Akhil Abraham Saji, MD

GU Oncology Now

Bladder cancer, and specifically non-muscle-invasive bladder cancer (NMIBC), can be a costly disease to treat. According to the American Cancer Society 2021 statistical analysis, 75% of all bladder cancer cases diagnosed in the United States are non-muscle-invasive at the time of diagnosis.<a href="https://www.cancer.org/cancer/bladder-cancer/about/key-statistics.html" target="_blank" rel="noopener">1</a> The goals for treatment of NMIBC include attempted removal of all visible tumor, with a focus on preventing future recurrence and minimizing impact on urinary function. Existing literature regarding NMIBC treatment demonstrates that its associated costs vary widely across types of treatments utilized, health systems, and regions of the country. Studies have estimated that NMIBC comprises more than 3% of all cancer-related payments in the United States.<a href="https://www.sciencedirect.com/science/article/abs/pii/S0302283814000189" target="_blank" rel="noopener">2</a> Patients, families, and clinicians should be aware of the significant costs that may be incurred throughout the course of treatment.All prices included in this article are based on estimates from the New York geographic area and provide a range of in-network and out-of-network costs. The first set of costs that most patients incur is related to initial diagnosis. Symptomatic patients (eg, those who experience gross hematuria) will undergo consultation with a urologist who will likely perform a cystoscopic analysis of the urinary bladder under local anesthesia. The final cost of this procedure is estimated to be between $2370 and $3524 with anesthesia.<a href="http://www.fairhealthconsumer.org/medical/results" target="_blank" rel="noopener">3</a> Once a tumor is identified, transurethral resection of bladder tumor (TURBT) is the gold standard of therapy. Estimates for TURBT range from $8381 to $8688.<a href="http://www.fairhealthconsumer.org/medical/results" target="_blank" rel="noopener">4</a>Costs can continue to rise if patients have significant tumor burden that prevents urologists from completing the full resection in a single session. Furthermore, the American Urologic Association (AUA) NMIBC guidelines recommend repeat resection on patients with high-risk disease, high grade Ta disease, or T1 disease within 6 weeks.<a href="https://www.auanet.org/guidelines-and-quality/guidelines/bladder-cancer-non-muscle-invasive-guideline" target="_blank" rel="noopener">5</a> The cost of repeat resections can increase the initial therapeutic costs of diagnosis and upfront treatment. Furthermore, the postoperative instillation of intravesical chemotherapy with either gemcitabine or mitomycin as recommended by the guidelines can potentially add to the cost of therapy.<a href="https://www.auanet.org/guidelines-and-quality/guidelines/bladder-cancer-non-muscle-invasive-guideline" target="_blank" rel="noopener">5</a>After the immediate postoperative period, patients with low-risk disease may be suitable candidates for surveillance.<a href="https://www.auanet.org/guidelines-and-quality/guidelines/bladder-cancer-non-muscle-invasive-guideline" target="_blank" rel="noopener">5</a> Surveillance protocols usually entail interval cystoscopic surveillance of the urinary bladder and may be combined with other tests such as urine cytology, which may contribute to cost burden. For patients with higher-risk disease (eg, intermediate or high risk), intravesical therapy with either immunotherapeutic agents or chemotherapeutic agents plays a critical role in disease control and management.Intravesical bacillus Calmette-Gu&eacute;rin (BCG), which can be utilized in both intermediate- and high-risk disease, has an estimated mean cost of approximately $2000 per patient.<a href="https://www.nature.com/articles/ncpuro0795" target="_blank" rel="noopener">6</a> Some studies have demonstrated that full- or even reduced-dose BCG protocols may be more useful in patients with high-risk disease who are at risk of progression rather than in the entire intermediate- or high-risk population.<a href="https://www.auajournals.org/doi/10.1097/JU.0000000000001023" target="_blank" rel="noopener">7</a> One study also demonstrated that costs for BCG and surveillance were comparable.<a href="https://www.auajournals.org/doi/10.1097/JU.0000000000001023" target="_blank" rel="noopener">7</a>Costs for intravesical chemotherapy are also important to consider. In addition to the cost of administration, chemotherapeutic agents such as mitomycin can have an average retail cost of $697 per vial.<a href="https://www.singlecare.com/prescription/mitomycin" target="_blank" rel="noopener">8</a> Some authors have demonstrated that despite the additional cost of intravesical chemotherapy in the immediate postoperative setting, the routine use of such agents cannot be associated with additional costs because they are also linked to future cost savings from lower follow-up and reoperation costs.<a href="https://www.sciencedirect.com/science/article/abs/pii/S0090429510001317" target="_blank" rel="noopener">9</a>In addition to procedural and medication costs, patients may incur indirect costs. Indirect costs of care such as lost wages related to taking time away from work for surgical therapy or doctors&rsquo; visits, as well as costs for transportation and outpatient medication, also contribute to a patient&rsquo;s final cost burden.Furthermore, since a new cancer diagnosis can put significant psychosocial stress on a patient and their family members, health care professionals must strive to provide patients with as much information as possible when interacting with them. Topics that may be of interest to patients include financial assistance programs, patient access programs, and insurance navigators. Financial assistance programs can help patients afford the cost of their care by offering discounts or low-interest loans from institutions like cancer centers or hospitals.Pharmaceutical companies also have programs to help patients afford medications that may be critical to more advanced and expensive immunotherapies such as pembrolizumab. Pembrolizumab is approved by AUA guidelines for use in patients with &ldquo;persistent or recurrent intermediate- to high-risk NMIBC within 12 months of completing adequate BCG therapy&rdquo; but is often considered to be extremely expensive, with a current market rate of $10,897.12 per 100-mg dose.<a href="https://www.keytruda.com/financial-support/" target="_blank" rel="noopener">10</a> Fortunately, large pharmaceutical corporations such as Merck offer patient access programs that can help subsidize the cost of immunotherapy in this setting.Insurance navigators can also help patients understand the often-complex terminology and details of insurance coverage. For example, they can assist patients with keeping track of deductibles and co-payments, and they can ensure that claims are processed appropriately and in a timely manner.Overall, the factors that influence care for NMIBC are complex and can be affected by a variety of factors, including geographic location, insurance status and coverage, and eligibility for special access programs. Empowering patients to understand the financial aspects of their care can play a critical role in compliance with therapy and possibly with therapeutic outcomes. Hopefully, such endeavors can help alleviate the stress and anxiety associated with cancer diagnoses. The impact of improved mental health and well-being can benefit patients and clinicians alike.Akhil Abraham Saji, MD is a urology resident at New York Medical College / Westchester Medical Center. His interests include urology education and machine learning applications in urologic care. He is a founding and current member of the EMPIRE Urology New York AUA section team.&nbsp;References:<ol>
<li>Key statistics for bladder cancer. American Cancer Society. Accessed April 24, 2023. <a href="https://www.cancer.org/cancer/bladder-cancer/about/key-statistics.html" target="_blank" rel="noopener">https://www.cancer.org/cancer/bladder-cancer/about/key-statistics.html</a></li>
<li>Svatek RS, Hollenbeck BK, Holm&auml;ng S, et al. The economics of bladder cancer: costs and considerations of caring for this disease. Eur Urol. 2014;66(2):253-262. doi:<a href="https://www.sciencedirect.com/science/article/abs/pii/S0302283814000189" target="_blank" rel="noopener">10.1016/j.eururo.2014.01.006</a></li>
<li>Medical and hospital costs. Diagnostic exam of bladder and urethra using an endoscope. FAIR Health Consumer. Accessed April 22, 2023. <a href="http://www.fairhealthconsumer.org/medical/results" target="_blank" rel="noopener">http://www.fairhealthconsumer.org/medical/results</a></li>
<li>Medical and hospital costs. Destruction and/or removal of growth of bladder and urethra using an endoscope, 2.0-5.0 cm. FAIR Health Consumer. Accessed April 22, 2023. <a href="http://www.fairhealthconsumer.org/medical/results" target="_blank" rel="noopener">http://www.fairhealthconsumer.org/medical/results</a></li>
<li>Diagnosis and Treatment of Non-Muscle Invasive Bladder Cancer: AUA/SUO Guideline (2020). American Urological Association. Accessed April 22, 2023. <a href="https://www.auanet.org/guidelines-and-quality/guidelines/bladder-cancer-non-muscle-invasive-guideline" target="_blank" rel="noopener">https://www.auanet.org/guidelines-and-quality/guidelines/bladder-cancer-non-muscle-invasive-guideline</a></li>
<li>Adjuvant, intravesical BCG therapy is cost-effective. Nat Rev Urol. 2007;4(6). doi:<a href="https://www.nature.com/articles/ncpuro0795" target="_blank" rel="noopener">10.1038/ncpuro0795</a></li>
<li>Sharma V, Wymer KM, Borah BJ, et al. Cost-effectiveness of maintenance bacillus Calmette-Gu&eacute;rin for intermediate and high risk nonmuscle invasive bladder cancer. J Urol. 2020;204(3):442-449. doi:<a href="https://www.auajournals.org/doi/10.1097/JU.0000000000001023" target="_blank" rel="noopener">10.1097/JU.0000000000001023</a></li>
<li>Mitomycin coupons &amp; prices. SingleCare. Accessed April 22, 2023. <a href="https://www.singlecare.com/prescription/mitomycin" target="_blank" rel="noopener">https://www.singlecare.com/prescription/mitomycin</a></li>
<li>Feifer A, Xie X, Brophy JM, Segal R, Kassouf W. Contemporary cost analysis of single instillation of mitomycin after transurethral resection of bladder tumor in a universal health care system. Urology. 2010;76(3):652-656. doi:<a href="https://www.sciencedirect.com/science/article/abs/pii/S0090429510001317" target="_blank" rel="noopener">10.1016/j.urology.2009.12.070</a></li>
<li>Cost info &amp; financial help. KEYTRUDA&reg; (pembrolizumab). Accessed April 22, 2023. <a href="https://www.keytruda.com/financial-support/" target="_blank" rel="noopener">https://www.keytruda.com/financial-support/</a></li>
</ol>

Understanding the Financial Considerations and Treatment Costs Related to NMIBC

Non-Muscle Invasive Urothelial Carcinoma

Existing literature regarding NMIBC treatment demonstrates that its associated costs vary widely across types of treatments, health systems, and regions.