Varying the intensity of cystoscopic surveillance for high‐risk non‐muscle‐invasive bladder cancer

ObjectivesTo compare the clinical, economic, and health utility outcomes associated with alternative cystoscopic surveillance regimens for high‐risk non‐muscle‐invasive bladder cancer (HRNMIBC).Patients and MethodsWe performed real‐world clinical data‐driven microsimulations of a hypothetical cohort of 100 000 patients diagnosed with HRNMIBC at age 70 years. The cohort was simulated to undergo alternative surveillance regimens recommended by five guidelines, and two hypothetical regimens—surveillance intensity escalation and de‐escalation—which had a surveillance intensity moderately higher and lower, respectively, than the guideline‐recommended regimens. We evaluated the 10‐year cumulative incidence of muscle‐invasive bladder cancer (MIBC), cancer‐specific survival (CSS), overall survival (OS), and cost‐effectiveness from a United States healthcare payer perspective.ResultsThe guideline‐recommended surveillance regimens led to an estimated 10‐year cumulative incidence of MIBC ranging from 11.0% to 11.6%, CSS 95.0% to 95.2%, and OS 69.7% to 69.8%. Surveillance intensity escalation resulted in a 10‐year cumulative incidence of MIBC of 10.5% (95% confidence interval [CI] 10.3–10.7%), CSS of 95.4% (95% CI 95.2–95.5%), and OS of 69.9% (95% CI 69.6–70.1%), vs 11.9% (95% CI 11.7–12.1%), 94.9% (95% CI 94.8–95.1%), and 69.6% (95% CI 69.3–69.9%), respectively, from surveillance intensity de‐escalation. By increasing surveillance intensity, the number‐needed‐to‐treat to prevent one additional MIBC progression over 10 years was ≥80, and ≥257 to avoid one additional cancer‐related mortality. Compared to surveillance intensity de‐escalation, higher‐intensity regimens incurred an incremental cost of ≥$336 000 per incremental quality‐adjusted life year gained, which well exceeded conventional willingness‐to‐pay thresholds, ≥$686 000 per additional MIBC progression prevented, and ≥$2.2 million per additional cancer‐related mortality avoided.ConclusionIn microsimulations testing a wide range of cystoscopic surveillance intensity for patients newly diagnosed with HRNMIBC, moderate surveillance de‐escalation appears associated with an insignificant change in 10‐year OS and furthermore is cost‐effective vs higher‐intensity surveillance regimens. These results suggest that moderate surveillance de‐escalation can reduce costs of care without compromising life expectancy for many patients.