| We studied three areas of bladder cancer care across the spectrum of clinical management, to identify areas of inequity in treatment and to determine the value of different treatment and surveillance options by assessing the costs and effectiveness of care. We used data from patients with bladder cancer diagnosed between 1991 and 2002 within the SEER-Medicare database. This provides nationally representative information on patient demographics, initial clinical management, survival time, and cause of death as well as the claims that are made to the Center for Medicare and Medicaid Services for those beneficiaries with fee-for-service coverage by Medicare. In the first study, we examined the association between clinical, demographic and socioeconomic factors and the receipt of systemic chemotherapy for bladder cancer. We found variation in treatment patterns, related to stage and grade disease, age, sex, comorbidity and cancer registry. In the second study, we compared the effectiveness of adjuvant intravesical therapy with transurethral resection alone and compared the direct medical costs associated with those two treatment approaches for patients with non-invasive, urothelial bladder cancer. After adjustment for several confounding variable, we found, in most stage and grade groups, that adjuvant therapy tended to increase costs and worsen time to recurrence and time to progression. However, subjects with poorly differentiated tumors that invaded the urothelium tended to benefit from adjuvant therapy: they had a lower risk of recurrence and death and a similar risk of progression. These findings may be subject to residual confounding and may reflect the fact that some subjects have more intensely managed bladder cancer, in general. In the third study we assessed the cost-effectiveness of the NMP-22 urinary marker relative to standard surveillance with cystoscopy and urinary cytology for patients with non-invasive, urothelial bladder cancer. We constructed a time-varying Markov model that replicated the rates of progression and death over 10 years for subjects identified in the SEER-Medicare database. We found that patients who used the NMP-22 marker had a mean of 6.8 fewer days with invasive and metastatic bladder and a mean of {dollar}1,607 less Medicare costs compared with patients that used standard surveillance. |
