Trimodal therapy may lead to significantly poorer survival outcomes and financial toxicity compared with radical cystectomy among patients with invasive bladder cancer, according to a study published in JAMA Surgery.1

Current guidelines recommend that patients with bladder cancer undergo radical cystectomy, but concerns with morbidity and mortality have led to a reemergence of trimodal “bladder-sparing” therapy. There is a lack of direct, head-to-head clinical studies evaluating radical cystectomy against trimodal therapy, however; comparative clinical and financial efficacy data of these modes of treatment requires further study.

For this population-based cohort study, researchers accessed the Surveillance, Epidemiology, and End Results (SEER)–Medicare-linked database and evaluated the outcomes data of 3200 older adults with clinical stage T2 to T4a bladder cancer. Patients identified as having received radical cystectomy underwent only surgery or surgery in combination with radio- or chemotherapy, and patients in the trimodal group underwent transurethral bladder resection followed by radiotherapy and chemotherapy.

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Of the identified patients, there were an equal number of patients (687; 21.5%) in both treatment arms.

Patients who underwent trimodal therapy had significantly shorter overall survival (hazard ratio [HR], 1.49; 95% CI, 1.31-1.69) and cancer-specific survival (HR, 1.55; 95% CI, 1.32-1.83) compared with patients who received radical cystectomy.

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There were no significant differences in cost between the 2 treatment groups at 30 days with trimodal therapy at $18,743 versus $21,738 for radical cystectomy (costs calculated in 2011). Total median costs for trimodal therapy however, were significantly higher at 90 days ($80,174 vs $69,181; median difference, $8964) and at 180 days ($179,891 vs $107,017; median difference, $63,771).

Further analysis extrapolating these findings to the US population showed that patients receiving trimodal therapy had $335 million in excess spending compared with those undergoing radical cystectomy in 2011.

The authors concluded that the “findings have important health policy implications regarding the appropriate use of high value-based care among older adults with invasive bladder cancer who are candidates for either radical cystectomy or trimodal therapy.”


  1. Williams SB, Shan Y, Jazzar U, et al. Comparing survival outcomes and costs associated with radical cystectomy and trimodal therapy for older adults with muscle-invasive bladder cancer [published online June 27, 2018]. JAMA Surg. doi: 10.1001/jamasurg.2018.1680