A recent study in JAMA Network Open found that although trimodal therapy (TMT) improved quality of life for patients with muscle-invasive bladder cancer, it was not as cost-effective as radical cystectomy.1 However, the immediate implication for clinicians is not to abandon TMT, but to be highly selective about patient choice, according to study author Daniel D. Joyce, MD, MS, assistant professor of urology at Vanderbilt University Medical Center in Nashville, Tennessee. TMT is best suited for patients with very limited disease who can maintain a good quality of life with their bladders, rather than those with extensive cancer or bilateral hydronephrosis. The goal is to improve the value of care by ensuring TMT is used in patients most likely to achieve metastasis-free and overall survival benefits.
Regarding policy changes to reduce TMT costs, Joyce brought up a comparison with the Canadian health care system. In Canada, TMT was found to be the most cost-effective option, with costs around $20,000 USD at 5 years, compared with $70,000 in the US.2 The primary driver of this cost difference in the US is radiation therapy, as chemotherapies are relatively inexpensive.
According to Joyce, policy initiatives should focus on improving the value and efficiency of radiation. This could involve re-evaluating current fee-for-service billing for radiation, which encompasses physician, facility, and per-fraction Current Procedural Terminology codes, to determine whether current expenditures are justified. Moving toward value-based or bundled payment programs for radiation is 1 potential option to promote higher value and efficiency. Additionally, broader societal discussions are needed concerning the density of high-cost technologies like proton beams to encourage efficiency.
REFERENCES
1. Joyce DD, Wymer KM, Graves JA, et al. Cost-effectiveness of trimodal therapy and radical cystectomy for muscle-invasive bladder cancer. JAMA Netw Open. 2025;8(6):e2517056. doi:10.1001/jamanetworkopen.2025.17056
2. Kool R, Yanev I, Hijal T, et al. Trimodal therapy vs. radical cystectomy for muscle-invasive bladder cancer: A Canadian cost-effectiveness analysis. Can Urol Assoc J. 2022;16(6):189-198. doi:10.5489/cuaj.7430