UROLOGICAL ONCOLOGY

Intravesical instillation of bacille Calmette-Guérin for superficial bladder cancer: cost-effectiveness analysis
Uchida A, Yonou H, Hayashi E, Iha K, Oda M, Miyazato M, Oshiro Y, Hokama S, Sugaya K, Ogawa Y
Department of Urology, University of the Ryukyus School of Medicine, Okinawa, Japan
Urology. 2007; 69: 275-9

• Objectives: Frequent recurrence of superficial bladder cancer is a major problem that impairs patients’ quality of life. We studied the current treatment of superficial bladder cancer, including the economic aspects of intravesical instillation.
• Methods: A total of 138 superficial bladder cancers were assessed. The tumor characteristics and treatments were investigated during a mean observation period of 86 months by univariate and multivariate analyses. The costs associated with intravesical instillation of bacille Calmette-Guérin (BCG) and its side effects were subjected to cost-effectiveness analysis.
• Results: Tumor histologic examination revealed grade 1 in 21 lesions, grade 2 in 60 lesions, grade 3 in 40 lesions, and unclassified in 17 lesions. The pathologic stage was Stage Ta in 85 lesions, T1 in 47 lesions, and Tis in 6 lesions. Univariate and multivariate analyses showed that intravesical instillation of BCG was the most significant factor preventing recurrence, and intravesical chemotherapy had no impact on recurrence. The 5-year recurrence-free survival rate was 78% and 28% for tumors with and without BCG instillation, respectively. The cost-effectiveness ratio of BCG instillation was approximately 3900 dollars/5-yr recurrence-free period.
• Conclusions: Our results have indicated that BCG is an effective adjuvant therapy after transurethral resection of superficial bladder cancer in the current medical environment.
  
  
• Editorial Comment
  The discussion on whether to give intravesical chemotherapy or immunotherapy is viable since many years. As these authors state “When prophylaxis with intravesical therapy is performed, it is necessary to strike a balance between more benefit with severe side effects versus less benefit with mild side effects.” The authors shed another perspective onto this discussion in analyzing and comparing the overall costs (including costs of e.g. antibiotics) of intravesical chemotherapy and BCG immunotherapy against superficial bladder cancer in 138 consecutive patients.
  The figures are based on the Japanese health care system. Still, they are meaningful for the treatment of superficial bladder cancer in toto.
  The treatment of BCG related complications are 11% of the total BCG treatment costs. As BCG treated patients had significantly lower recurrence rates, the cost-effectiveness ratio was clearly in favor of BCG immunotherapy with 525 US$ per year.

Dr. Andreas Bohle
Professor of Urology
HELIOS Agnes Karll Hospital
Bad Schwartau, Germany