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Objective: Nivolumab, recently proven in a phase 3 clinical trial (CheckMate 901) to enhance survival when combined with gemcitabine-cisplatin for advanced urothelial carcinoma. This study aimed to assess its cost-effectiveness against gemcitabine-cisplatin alone, from US and Chinese payers' perspectives., Methods: A partitioned survival model was established to assess the life-years, quality-adjusted life-years (QALYs), lifetime costs, and incremental cost-effectiveness ratios (ICERs) of nivolumab plus gemcitabine-cisplatin versus gemcitabine-cisplatin alone as first-line treatment for advanced urothelial carcinoma. Univariate, two-way, and probabilistic sensitivity analyses were conducted to assess the model's robustness. Additionally, subgroup analyses were performed., Results: Nivolumab plus gemcitabine-cisplatin and gemcitabine-cisplatin achieved survival benefits of 4.238 life-years and 2.979 life-years for patients with advanced urothelial carcinoma, respectively. Compared with gemcitabine-cisplatin, nivolumab plus gemcitabine-cisplatin resulted in ICERs of $116,856/QALY in the US and $51,997/QALY in China. The probabilities of achieving cost-effectiveness at the current willingness-to-pay thresholds were 77.5% in the US and 16.5% in China. Cost-effectiveness could be reached if the price of nivolumab were reduced to $920.87/100mg in China. Subgroup analyses indicated that the combination had the highest probability of cost-effectiveness in patients under 65 or with an Eastern Cooperative Oncology Group (ECOG) performance-status score of 0 in the US and China., Conclusion: Nivolumab plus gemcitabine-cisplatin first-line treatment for advanced urothelial carcinoma results in longer life expectancy than gemcitabine-cisplatin, but is not cost-effective in China at current price. However, cost-effectiveness is likely to be achieved in most patient subgroups in the US., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Xiang, Huang, Gan, Wang, Ding, Wu, Xing and Liu.)

Background and Objective: The EV-302 trial found that the combination of enfortumab vedotin (EV) with pembrolizumab significantly improved survival for patients with metastatic urothelial carcinoma (mUC). However, given the high cost of the drugs, there is a need to assess its value by considering both efficacy and cost. This study assessed the cost-effectiveness of EV plus pembrolizumab as a first-line treatment for patients with mUC from the perspective of U.S. payers., Methods: A Markov model was developed to compare the lifetime costs and effectiveness of EV in combination with pembrolizumab with chemotherapy in the treatment of mUC patients from U.S. payer perspective. Life-years (LYs), quality-adjusted LYs (QALYs), and lifetime costs were estimated. One-way, two-way and probabilistic sensitivity analyses were conducted to evaluate model uncertainty. Additionally, subgroup analyses were performed., Results: Compared to chemotherapy, the combination of EV and pembrolizumab provided an additional 2.10 LYs and 1.72 QALYs, at an incremental cost of $962,240.8 per patient. The incremental cost-effectiveness ratio (ICER) is $558,973 per QALY. Subgroup analysis indicated that patients ineligible for cisplatin treatment had a lower ICER compared to those who were eligible for cisplatin., Conclusions: From the perspective of US payers, at a willingness-to-pay threshold of $150,000 per QALY, the combination of EV and pembrolizumab is estimated to not be cost-effective compared to traditional chemotherapy in the first-line treatment of mUC patients., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Li, Wu, Xie, Xiang, Meng, Tan, Wang and Wan.)

Background: Relaxed licensing restrictions on telehealth use during the COVID-19 pandemic allowed broad use irrespective of visit type. As these telehealth waivers expire, optimal uses of telehealth must be assessed to inform policy and clinical care. We evaluated patient experience associated with telehealth and in-person new or established visits., Methods: Patients seen in-person and via telehealth for urologic cancer care from August 2019 to June 2022 received a survey on satisfaction with care, perceptions of communication during their visit, travel time, travel costs, and days of work missed. We assessed survey responses with descriptive statistics., Results: Surveys were completed for 1,031 patient visits (N = 494 new visits, N = 537 established visits). Satisfaction rates were high for all visit modalities among new and established patients (mean score range 59.9-60.7 [maximum 63], P > 0.05). Patient-rated quality of the encounter did not differ by visit type and modality (P > 0.05, for nearly all comparisons). New in-person patient visits were associated with significantly higher travel costs (mean $496.10, SD $1021) compared with new telehealth visits (mean $26.60, SD $141; P < 0.001); 27% of new in-person patients required plane travel and 41% required a hotel stay (P < 0.001 vs. 0.8% and 3.2% of new telehealth patients, respectively)., Conclusions: Satisfaction outcomes among patients with urologic cancer receiving new patient telehealth care equaled those of new patients cared for in-person while costs were significantly lower. Offering telehealth exemption beyond COVID-19 licensing waivers to include new patient visits would allow for ongoing delivery of high-quality urologic cancer care irrespective of geographic location., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: This study examined the impact of cannabis use disorder (CUD) on inpatient morbidity, length of stay (LOS), and inpatient cost (IC) of patients undergoing urologic oncologic surgery., Methods: The National Inpatient Sample (NIS) from 2003 to 2014 was analyzed for patients undergoing prostatectomy, nephrectomy, or cystectomy (n = 1,612,743). CUD was identified using ICD-9 codes. Complex-survey procedures were used to compare patients with and without CUD. Inpatient major complications, high LOS (4th quartile), and high IC (4th quartile) were examined as endpoints. Univariable and multivariable analysis (MVA) were performed to compare groups., Results: The incidence of CUD increased from 51 per 100,000 admissions in 2003 to 383 per 100,000 in 2014 (p < 0.001). Overall, 3,503 admissions had CUD. Patients with CUD were more frequently younger (50 vs. 61), male (86% vs. 78.4%), Black (21.7% vs. 9.2%), and had 1st quartile income (36.1% vs. 20.6%); all p < 0.001. CUD had no impact on any complication rates (all p > 0.05). However, CUD patients had higher LOS (3 vs. 2 days; p < 0.001) and IC ($15,609 vs. $12,415; p < 0.001). On MVA, CUD was not an independent predictor of major complications (p = 0.6). Conversely, CUD was associated with high LOS (odds ratio (OR) 1.31; 95% CI 1.08-1.59) and high IC (OR 1.33; 95% CI 1.12-1.59), both p < 0.01., Conclusion: The incidence of CUD at the time of urologic oncologic surgery is increasing. Future research should look into the cause of our observed phenomena and how to decrease LOS and IC in CUD patients., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: This study evaluated the cost-effectiveness of avelumab first-line (1L) maintenance therapy plus best supportive care (BSC) versus BSC alone for adults with locally advanced or metastatic urothelial carcinoma (la/mUC) that had not progressed following platinum-based chemotherapy in France., Methods: A three-state partitioned survival model was developed to assess the lifetime costs and effects of avelumab plus BSC versus BSC alone. Data from the phase 3 JAVELIN Bladder 100 trial (NCT02603432) were used to inform estimates of clinical and utility values considering a 10-year time horizon and a weekly cycle length. Cost data were estimated from a collective perspective and included treatment acquisition, administration, follow-up, adverse event-related hospitalization, transport, post-progression, and end-of-life costs. Health outcomes were measured in quality-adjusted life-years (QALYs) and life-years gained. Costs and clinical outcomes were discounted at 2.5% per annum. Incremental cost-effectiveness ratios (ICERs) were used to compare cost-effectiveness and willingness to pay in France. Uncertainty was assessed using a range of sensitivity analyses., Results: Avelumab plus BSC was associated with a gain of 2.49 QALYs and total discounted costs of €136,917; BSC alone was associated with 1.82 QALYs and €39,751. Although avelumab plus BSC was associated with increased acquisition costs compared with BSC alone, offsets of -€20,424 and -€351 were observed for post-progression and end-of-life costs, respectively. The base case analysis ICER was €145,626/QALY. Sensitivity analyses were consistent with the reference case and showed that efficacy parameters (overall survival, time to treatment discontinuation), post-progression time on immunotherapy, and post-progression costs had the largest impact on the ICER., Conclusions: This analysis demonstrated that avelumab plus BSC is associated with a favorable cost-effectiveness profile for patients with la/mUC who are eligible for 1L maintenance therapy in France., Competing Interests: F. Porte is an employee of Merck Santé S.A.S., Lyon, France, an affiliate of Merck KGaA, Darmstadt, Germany at the time of the project. A. Granghaud was an employee of Pfizer S.A.S., Paris, France at the time of the study. J. Chang is an employee of Pfizer and holds stock and other ownership interest with Bayer, Bristol Myers Squibb, and Pfizer. M. Kearney is an employee of Merck KGaA, Darmstadt, Germany, and holds stock in Merck KGaA, Darmstadt, Germany, Novartis and UCB. A. Morel is an employee of Pfizer S.A.S., Paris, France. I. Plessala was an employee of Amaris Consulting, Paris, France at the time of the study. H. Cawston is an employee of Amaris Consulting, Paris, France. J. Roiz is an employee of and reposts stocks and other ownership interest with Evidera. Y. Xiao is an employee of Evidera. M.-N. Solbes is an employee of Merck Santé S.A.S., Lyon, France, an affiliate of Merck KGaA, Darmstadt, Germany. P. Lambert is an employee of Pfizer S.A.S., Paris, France. A. Ravaud has received grants or contracts from Merck KGaA, Darmstadt, Germany, and Pfizer; has received travel and accommodation expenses from Ipsen Merck KGaA, Darmstadt, Germany, Merck & Co., Kenilworth, NJ, and Pfizer; and has participated in advisory boards for Esai, Ipsen, Merck KGaA, Darmstadt, Germany, and Pfizer. Y. Loriot has served in consulting or advisory roles for Astellas Pharma, Bristol Myers Squibb, Immunomedics, Janssen, Loxo/Lilly, Merck KGaA, Darmstadt, Germany, Merck & Co., Kenilworth, NJ, Pfizer, Roche, Seattle Genetics, and Taiho Pharmaceutical; has received travel and accommodations expenses from Astellas Pharma, Janssen Oncology, Merck & Co., Kenilworth, NJ, Roche, and Seattle Genetics; and has received institutional research funding from Astellas Pharma, Basilea, Bristol Myers Squibb, Exelixis, Gilead Sciences, Incyte, Janssen Oncology, Merck KGaA, Darmstadt, Germany, Merck & Co., Kenilworth, NJ, Nektar, Pfizer, Roche, Sanofi, Seattle Genetics, and Taiho Pharmaceutical. A. Thiery-Vuillemin has participated in advisory boards for Astellas Pharma, AstraZeneca, Bristol-Myers Squibb, Ipsen, Janssen, Merck & Co., Kenilworth, NJ, Novartis, Pfizer, Roche/Genentech and Sanofi; reports employment by Bristol Myers Squibb; has served on steering committees for AstraZeneca, Bristol-Myers Squibb and Novartis; has received institutional research funding from Bayer, Ipsen and Pfizer; has served as principal investigator for Astellas Pharma, AstraZeneca, Bristol-Myers Squibb, Excelixis, Incyte, Ipsen, Johnson & Johnson, Merck & Co., Kenilworth, NJ, Novartis, Pfizer, Roche, Sanofi, and UNICANCER/GETUG; has received travel and accommodation expenses from Astellas Pharma, AstraZeneca, Bristol-Myers Squibb, Ipsen, Johnson & Johnson, Merck & Co., Kenilworth, NJ, Pfizer and Roche; and is a member of ASCO and GETUG. P. Lévy has served in consulting or advisory role and had received honoraria from Merck KGaA, Darmstadt, Germany. This does not alter our adherence to PLOS ONE policies on sharing data and materials, (Copyright: © 2024 Porte et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objective: To determine if use of the hematuria risk index can reduce testing and cost, while maintaining equivalent lesion detection in patients with asymptomatic microscopic hematuria., Materials and Methods: Retrospective cohort study of 1049 patients at single institution. Hematuria risk index score was calculated based on clinical factors including age, sex, smoking history, and degree of hematuria for each patient along with evaluation studies performed and total number of tumors discovered. Cost benefit analysis was performed based on published Medicare averages., Results: Tumor detection rate in overall, low-risk, and moderate-risk groups were 1.2%, 0%, and 2.96% at a total cost of $408,376. When low-risk group is not screened cost decreases to $166,252 with no lesions missed. The cost to discover one lesion/cancer in the overall group was $34,031.3, the cost to find one high-grade clinically significant lesion/cancer was $136,125.3 for the overall group. When the low-risk group was removed, the cost to find a high-grade clinically significant lesion/cancer decreased to $55,417.3 without missing any significant lesions. Ultrasound may be utilized instead of computed tomography with minimal loss of lesion detection in select moderate risk patients., Conclusion: None of the low-risk hematuria risk patients were diagnosed with any lesions, as such these patients may not need an evaluation. Furthermore, by utilizing a risk-stratified approach to the assessment of asymptomatic microscopic hematuria health care costs can be significantly decreased with limited negative consequences in terms of lesion detection., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: This study examined the prevalence of financial toxicity (FT) and associated factors among urologic cancer patients. The association between FT and health-related quality of life (HRQoL) was also investigated., Methods: A total of 429 respondents diagnosed with urologic cancers (prostate cancer, bladder and renal cancer) from Sarawak General Hospital and Subang Jaya Medical Centre in Malaysia were interviewed using a structured questionnaire. Objective and subjective FT were measured by catastrophic health expenditure (healthcare-cost-to-income ratio greater than 40%) and the Personal Financial Well-being Scale, respectively. HRQoL was measured with the Functional Assessment of Cancer Therapy - General 7 Items scale., Results: Objective and subjective FT were experienced by 16.1 and 47.3% of the respondents, respectively. Respondents who sought treatment at a private hospital and had out-of-pocket health expenditures were more likely to experience objective FT, after adjustment for covariates. Respondents who were female and had a monthly household income less than MYR 5000 were more likely to experience average to high subjective FT. Greater objective FT (OR = 2.75, 95% CI 1.09-6.95) and subjective FT (OR = 4.68, 95% CI 2.63-8.30) were associated with poor HRQoL., Conclusions: The significant association between both objective and subjective FT and HRQoL highlights the importance of reducing FT among urologic cancer patients. Subjective FT was found to have a greater negative impact on HRQoL.

Background: There is an unmet need for effective therapies for patients with advanced or metastatic urothelial cancer who cannot tolerate cisplatin-based chemotherapy. Cisplatin-ineligible patients experience a high frequency of adverse events from the most commonly used standard of care treatment, carboplatin plus gemcitabine, or alternative treatment with gemcitabine monotherapy. Pembrolizumab is a potent, highly selective humanised monoclonal antibody that releases checkpoint inhibition of the immune response system, and provides a new alternative for these patients., Objective: To assess the cost-effectiveness of pembrolizumab for first-line treatment of urothelial carcinoma ineligible for cisplatin-based therapy in patients with strongly PD-L1-positive tumours in Sweden., Design, Setting, and Participants: Parametric survival curves were fitted to overall survival, progression-free survival, and time on treatment data from KEYNOTE-052 to extrapolate clinical outcomes. A simulated treatment comparison and a network meta-analysis were conducted to estimate the comparative efficacy of pembrolizumab versus carboplatin plus gemcitabine and gemcitabine monotherapy. EQ-5D data from KEYNOTE-052 were used to estimate utility, while resource use and cost inputs were estimated using Swedish regional pricing lists and clinician opinion., Outcome Measurements and Statistical Analysis: The model reported costs, life years, and quality-adjusted life years (QALYs), and results were tested using deterministic and probabilistic sensitivity analysis., Results and Limitations: We estimated that pembrolizumab would improve survival by 2.11 and 2.16 years and increase QALYs by 1.71 and 1.75 compared to carboplatin plus gemcitabine and gemcitabine monotherapy, respectively. Pembrolizumab was associated with a cost increase of €90520 versus carboplatin plus gemcitabine and €95055 versus gemcitabine, with corresponding incremental cost-effectiveness ratios of €53055/QALY and €54415/QALY., Conclusions: At a willingness-to-pay threshold of €100000/QALY, pembrolizumab is a cost-effective treatment versus carboplatin plus gemcitabine and versus gemcitabine., Patient Summary: This is the first analysis to show that pembrolizumab is a cost-effective option for first-line treatment of cisplatin-ineligible patients with locally advanced or metastatic urothelial carcinoma in Sweden., (Copyright © 2018 Merck Sharp & Dohme Corp and The Authors. Published by Elsevier B.V. All rights reserved.)

As part of its Single Technology Appraisal (STA) process, the National Institute for Health and Care Excellence (NICE) invited the manufacturer (Merck Sharp & Dohme) of pembrolizumab (Keytruda ® ) to submit evidence of its clinical and cost effectiveness for the treatment of locally advanced or metastatic urothelial cancer where cisplatin is unsuitable. The School of Health and Related Research Technology Appraisal Group at the University of Sheffield was commissioned to act as the independent Evidence Review Group (ERG). The ERG produced a detailed review of the evidence for the clinical and cost effectiveness of the technology, based on the company's submission (CS) to NICE. The clinical effectiveness evidence in the CS for pembrolizumab was based on one phase II, single-arm, open-label, non-randomised study (KEYNOTE-052), while the evidence for the comparator (carboplatin plus gemcitabine) was based on four studies, including one randomised controlled trial and three cohort studies. In the absence of head-to-head trials, the company conducted an indirect treatment comparison for both progression-free survival (PFS) and overall survival (OS), by firstly adjusting cross-study differences using a simulated treatment comparison approach and then synthesizing the evidence based on an assumption of constant hazard ratios using a standard meta-analysis model and time-varying hazard ratios using fractional polynomial models. The treatment effect of pembrolizumab was more favourable in the adjusted population compared with the observed effect in the KEYNOTE-052 study. The company submitted a de novo partitioned survival cohort simulation model, which partitions the OS time into PFS and post-progression survival. The probabilistic incremental cost-effectiveness ratio (ICER) for pembrolizumab compared with carboplatin plus gemcitabine was estimated to be £37,081 per quality-adjusted life-year (QALY) gained, based on the results within the company's health economic model. Following a critique of the model, for their preferred base case the ERG corrected some minor model errors, chose a progression approach for estimating utilities, and revised the extrapolation of PFS and OS. The ERG's probabilistic base case ICER was estimated to be £67,068 per QALY gained. The ERG also undertook a range of exploratory sensitivity analyses which suggested that the ICER was highly uncertain. In particular, the choices of extrapolation for the OS of pembrolizumab and the stopping rule for pembrolizumab had the largest impacts on the ICER. The NICE Appraisal Committee recommended pembrolizumab for use within the Cancer Drugs Fund as an option for treating locally advanced or metastatic urothelial carcinoma in adults who have had platinum-containing chemotherapy, provided that pembrolizumab was stopped at 2 years of uninterrupted treatment, or earlier if the disease progresses, and the conditions of the managed access agreement for pembrolizumab are followed.

Pembrolizumab is an intravenously administered monoclonal antibody licensed for locally advanced or metastatic urothelial carcinoma after platinum-containing chemotherapy. This summary presents the perspective of Warwick Evidence, the Evidence Review Group (ERG) appointed by the National Institute of Health and Care Excellence (NICE) for the single technology appraisal of pembrolizumab for this indication. Pembrolizumab is manufactured by Merck, Sharp and Dohme (MSD). The major source of clinical effectiveness was the KEYNOTE-045 trial, where 542 patients received either pembrolizumab or clinician's choice of docetaxel, paclitaxel or vinflunine as a second-line treatment. No indirect treatment comparison was performed. The clinical effectiveness was assessed using hazard ratios for overall survival (OS) and progression-free survival (PFS) of the intention-to-treat (ITT) population, together with the subpopulations positive for programmed cell death 1 ligand 1 (PD-L1) expression (combined positive score [CPS] ≥ 1%) and strongly positive for PD-L1 expression (CPS ≥ 10%). In the ITT population, OS improved with pembrolizumab (HR 0.73, 95% CI 0.59-0.91) while PFS outcomes showed no difference (HR 0.98, 95% CI 0.81-1.19). Pembrolizumab demonstrated a better safety profile than its combined comparators, with fewer patients experiencing adverse events (60.9 vs 90.2%). Similar results were observed in populations expressing PD-L1. MSD estimated the cost effectiveness of pembrolizumab using a de novo partitioned survival model. The model had three health states: pre-progression, post-progression and death, where OS and PFS estimates excluded patients who received vinflunine. The largest uncertainty was over the selection of the parametric models used to extrapolate OS and PFS and the time point for when to begin their extrapolation. The company preferences for extrapolation were not well supported and the ERG disagreed with their selection for OS. Utility values were also contentious, with the company preferring to use pooled time-to-death-based utilities pooled across treatment arms, whilst the ERG preferred pooled progression-based utilities. The company preferred to use data from patients receiving vinflunine when calculating the utility values, which the ERG disagreed with as this is not recommended treatment within the UK. The company assumed a lifetime treatment effect for their model; however, the lack of evidence made it difficult to confidently provide a realistic estimate of treatment effect duration. Various durations were explored (3, 5 and 10 years). The first appraisal committee meeting concluded that pembrolizumab was not cost effective, largely due to uncertainty in the OS and PFS extrapolations. The company's second submission included an additional 4 months follow-up to survival data. The company in this new submission maintained their original assumptions in their base-case analysis, changing only the choice of parametric curve for PFS. This change resulted in the OS and PFS curves intersecting at 6 years in the pembrolizumab arm, at which point PFS identically followed OS. This resulted in no patients in the post-progression health state beyond this time point, and therefore, the majority of pembrolizumab's benefit came from pre-progression survival. Given the unclear PFS benefit, the ERG found this implausible and maintained their original base-case model assumptions. Considerable uncertainty remained over the specification of the extrapolations and the duration of treatment effect. Based on a new-value proposition submitted by the company, the appraisal committee concluded that pembrolizumab had plausible potential to be cost effective. Pembrolizumab was referred for funding through the Cancer Drugs Fund, so that further data could be collected with the aim of diminishing the outstanding uncertainties pertaining to its clinical effectiveness.

Background: Safety-net hospitals (SNHs) care for more patients of low socioeconomic status (SES) than non-SNHs and are disproportionately punished under SES-naive Medicare readmission risk-adjustment models. This study was designed to develop a risk-adjustment framework that incorporates SES and to assess the impact on readmission rates., Methods: California Office of Statewide Health Planning and Development data from 2007 to 2011 were used to identify patients undergoing radical cystectomy (RC) for bladder cancer (n = 3771) or partial nephrectomy (PN; n = 5556) or radical nephrectomy (RN; n = 13,136) for kidney cancer. Unadjusted hospital rankings and predicted rankings under models simulating the Medicare Hospital Readmissions Reduction Program were compared with predicted rankings under models incorporating SES and hospital factors. SES, derived from a multifactorial neighborhood score, was calculated from US Census data., Results: The 30-day readmission rate was 26.1% for RC, 8.3% for RN, and 9.5% for PN. The addition of SES, geographic, and hospital factors changed hospital rankings significantly in comparison with the base model (P < .01) except for SES for RC (P = .07) and SES and rural factors for PN (P = .12). For RN and PN, the addition of SES predicted lower percentile ranks for SNHs and thus improved observed-to-expected rankings (P < .01). For RC, there were no changes in hospital rankings., Conclusions: SES is important for risk adjustments for complex surgical procedures such as RC. Patient SES affects overall hospital rankings across cohorts, and critically, it differentially and punitively affects rankings for SNHs for some procedures. Cancer 2018. © 2018 American Cancer Society., (© 2018 American Cancer Society.)

For the management of muscle-invasive bladder cancer or upper tract urothelial carcinoma, the set guidelines recommend regular surveillance after radical cystectomy or radical nephroureterectomy. However, the prognostic benefit of regular oncological surveillance remains controversial in the absence of prospective studies although several retrospective studies with relatively large sample sizes have demonstrated the association between asymptomatic recurrence and better oncological outcomes. Seven out of eight studies reported that patients diagnosed with symptomatic recurrence showed significantly poorer prognosis in comparison to those diagnosed with asymptomatic recurrence. However, potential lead-time and length-time biases prevent the determination of any benefit of regular surveillance. In addition, an optimal surveillance protocol has yet to be established because conventional pathology-based protocols cannot identify the heterogenetic tumor biology of urothelial carcinoma, such as rapid- or slow-growing form of the disease. Several studies suggest that conventional pathology-based surveillance resulted in reduced cost-effectiveness. Recurrence risk-score stratified surveillance protocol including clinical and pathological factors may improve cost-effectiveness. The establishment of optimal risk stratification and surveillance strategies are required to improve the efficacy of regular oncological surveillance. Well-planned prospective studies are necessary to address the prognostic benefit of regular oncological surveillance and shared decision making.

Objective: Urologic cancers are not only among the most common types of cancers, but also among the most expensive cancers to treat in the United States. This study aimed to review the use of CEAs and other cost analyses in urologic oncology using large databases to better understand the value of management strategies of these cancers., Methods: A literature review on CEAs and other cost analyses in urologic oncology using large databases., Results: The options for and costs of diagnosing, treating, and following patients with urologic cancers can be expected to rise in the coming years. There are numerous opportunities in each urologic cancer to use CEAs to both lower costs and provide high-quality services. Improved cancer care must balance the integration of novelty with ensuring reasonable costs to patients and the health care system., Conclusion: With the increasing focus cost containment, appreciating the value of competing strategies in caring for our patients is pivotal. Leveraging methods such as CEAs and harnessing large databases may help evaluate the merit of established or emerging strategies., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: To investigate payment variation for 3 common urologic cancer surgeries and evaluate the potential for applying bundled payment programs to these procedures., Methods: Using 2008-2011 Surveillance, Epidemiology, and End Results-Medicare linked data, we identified all beneficiaries aged greater than 65 years who underwent cystectomy, prostatectomy, or nephrectomy for cancer. Total episode payments were determined by aggregating hospital, professional, and post-acute care claims from the index surgical hospitalization through 90 days post discharge. Total episode payments were then compared to examine hospital level-variation within each procedure type and the specific payment components (ie, index hospitalization, professional, readmission, and post-acute care) driving spending variation., Results: Ninety-day episodes of care were identified for 1849 cystectomies, 8770 prostatectomies, and 4304 nephrectomies. We observed wide variation in mean episode payments for all 3 conditions (cystectomy mean $35,102: range $24,112-$57,238, prostatectomy mean $10,803: range $8,816-$17,877, nephrectomy mean $17,475: range $11,681-$26,711). Majority of payment variation was attributable to index hospitalization and post-acute care for cystectomy and nephrectomy and professional payments for prostatectomy. The most expensive hospitals by procedure each demonstrated a unique opportunity for spending reduction due to individual differences in component payment patterns between hospitals., Conclusion: Ninety-day episode payments for urologic cancer surgery vary widely across hospitals in the United States. The key drivers of this payment variation differ for individual procedures and hospitals. Accordingly, hospitals will need individualized data and clinical re-design strategies to succeed with implementation of episode-based payment models for urologic cancer care., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: To perform a population-based study to evaluate contemporary utilisation trends, morbidity, and costs associated with nephroureterectomies (NUs), as contemporary data for NUs are largely derived from single academic institution series describing the experience of high-volume surgeons and it is unclear if the same favourable results occur at a national level., Patients and Methods: Using the Premier Hospital Database, we captured patients undergoing a NU with diagnoses of renal pelvis or ureteric neoplasms from 2004 to 2013. We fitted regression models, adjusting for clustering by hospitals and survey weighting to evaluate 90-day postoperative complications, operating-room time (OT), prolonged length of stay (pLOS), and direct hospital costs among open (ONU), laparoscopic (LNU) and robotic (RNU) approaches., Results: After applying sampling and propensity weights, we derived a final study cohort of 17 254 ONUs, 13 317 LNUs and 3774 RNUs for upper tract urothelial carcinoma (UTUC) in the USA between 2004 and 2013. During that period, minimally invasive NU (miNU) increased from 36% to 54%, while the total number of NUs decreased by nearly 20%. No differences were noted in perioperative outcomes between the three surgical approaches, including when the analysis was restricted to the highest-volume hospitals and highest-volume surgeons. The OT was longer for LNU and RNU (P < 0.001), while the pLOS rates were decreased (P < 0.001). Adjusted 90-day median direct hospital costs were higher for LNU and RNU (P < 0.001), which disappeared when adjusting for the highest-volume groups, except for RNUs performed by high-volume surgeons., Conclusions: During this contemporary 10-year study, miNU has been replacing ONU for UTUC with a recent surge in RNU, along with a concurrent reduction in total NUs performed. Despite not being associated with a clinically significant improvement in perioperative outcomes, the costs for miNUs were consistently higher. However, higher hospital volumes suggest a potential cost containment strategy when performing miNUs., (© 2015 The Authors BJU International © 2015 BJU International Published by John Wiley & Sons Ltd.)

Surgical robotic use has grown exponentially in spite of limited or uncertain benefits and large costs. In certain situations, adoption of robotic technology provides value to patients and society. In other cases, however, the robot provides little or no increase in surgical quality, with increased expense, and, therefore, does not add value to health care. The surgical robot is expensive to purchase, maintain and operate, and can contribute to increased consumerism in relation to surgical procedures, and increased reliance on the technology, thus driving future increases in health-care expenditure. Given the current need for budget constraints, the cost-effectiveness of specific procedures must be evaluated. The surgical robot should be used when cost-effective, but traditional open and laparoscopic techniques also need to be continually fostered.

Introduction: While there is good evidence of the effectiveness of a variety of interventions and services to prevent and/or relieve distress experienced by people affected by cancer, much of this psychosocial morbidity is undetected and untreated, with consequent exacerbated suffering, decreased satisfaction with care, impaired adherence to treatment regimens and poorer morbidity and mortality outcomes. The objective of this study is to develop, implement and assess the impact, acceptability and cost of an integrated, patient-centred Psychosocial Assessment, Care and Treatment (PACT) model of care for patients with urological and head and neck cancers., Methods and Analysis: A time series research design will be used to test the PACT model of care, newly introduced in an Australian tertiary hospital. The primary outcome is system-level impact, assessed through audit of patients' medical records and Medicare claims for follow-up care. The secondary outcomes are impact of the model on patients' experience and healthcare professionals' (HCPs) knowledge and confidence, assessed via patient and HCP surveys at baseline and at follow-up. Acceptability of the intervention will be assessed through HCP interviews at follow-up, and cost will be assessed from Medicare and Pharmaceutical Benefits Scheme claims information and information logged pertaining to intervention activities (eg, time spent by the newly appointed psycho-oncology staff in direct patient contact, providing training sessions, engaging in case review) and their associated costs (eg, salaries, training materials and videoconferencing)., Ethics and Dissemination: Ethics approval was obtained from the Human Research Ethics Committees of Hunter New England Local Health District and the University of NSW., Results: The results will be widely disseminated to the funding body and through peer-reviewed publications, HCP and consumer publications, oncology conferences and meetings., Trial Registration: The study is registered with the Australian New Zealand Clinical Trials Registry with registration number ACTRN12613000916741.

In March 2010, the Patient Protection and Affordable Care Act as well as its amendments were signed into law. This sweeping legislation was aimed at controlling spiraling healthcare costs and redressing significant disparities in healthcare access and quality. Cancer diagnoses and their treatments constitute a large component of rising healthcare expenditures and, not surprisingly, the legislation will have a significant influence on cancer care in the USA. Because genitourinary malignancies represent an impressive 25% of all cancer diagnoses per year, this legislation could have a profound impact on urologic oncology. To this end, we will present key components of this landmark legislation, including the proposed expansion to Medicaid coverage, the projected role of Accountable Care Organizations, the expected creation of quality reporting systems, the formation of an independent Patient-Centered Outcomes Research Institute, and enhanced regulation on physician-owned practices. We will specifically address the anticipated effect of these changes on urologic cancer care. Briefly, the legal ramifications and current barriers to the statutes will be examined., (Published by Elsevier Inc.)

The future practice of urologic oncology in the United States will be influenced by a variety of factors. The national economic crisis has already impacted reimbursement and coverage for clinical care and has had a direct effect on the level of research funding. Unhealthy lifestyles by a significant segment of the American population contributes to a increased risk of most urologic cancers. Compounding these challenges is the aging of the urological workforce and projected significant manpower shortages. These multiple factors must be confronted directly or the future quality of urologic cancer care will be jeopardized., (Copyright © 2012 Elsevier Inc. All rights reserved.)

In less than a decade, the widespread application of robotic technology to the field of urologic oncology has permanently altered the way urologists approach malignancy. The short-term benefits of minimally invasive surgery using robotic assistance (i.e., decreased blood loss, improved convalescence and ergonomic appeal), as well as a broad marketing campaign, have helped the technology gain traction in the field of urology. Although the long-term benefits of its use in urologic surgery are less clear and the costs of robotic surgery are consistently greater than those of other approaches, the numbers of prostate, kidney and bladder cancer cases continue to rise. Identifying transferable surgical processes of care that matter most for each of the robotic cases in urologic oncology (e.g., prostatectomy, cystectomy and partial nephrectomy) is a next step toward broadly improving the quality of urologic cancer care. To this end, urologic professional societies and their surgeons should aim to identify underwriters for and participate in large clinical registries and surgical quality collaboratives.

A group of Swedish oncologists and hospital physicists have estimated the number of patients in Sweden suitable for proton beam therapy. The estimations have been based on current statistics of tumour incidence, number of patients potentially eligible for radiation treatment, scientific support from clinical trials and model dose planning studies and knowledge of the dose-response relations of different tumours and normal tissues. In prostate cancer it is estimated that annually about 300 patients and in gynaecological cancer about 50 patients, are candidates for proton beam therapy. Owing to major uncertainties, it has not been possible to give an estimate of the number of potential patients with urinary bladder cancer.

The guiding principles of the predominant methods of economic evaluation, cost-effectiveness analysis and cost-utility analysis, are briefly outlined, stressing the usefulness of the methods as a systematic approach to a structured and consistent analysis of decision problems, e.g. involving choices between treatment alternatives. The paper continues with an assessment of state of the art of economic evaluations of urinary tract cancers, based on a comprehensive survey of the available publications, which are limited to bladder cancer and advanced prostate cancer. Following a description of the methods employed in the relatively few existing studies and their results, it is concluded that they are of very dubious value in providing reliable guidance on the relative costs and benefits of treatment alternatives, as they are very rudimentary and usually based on data of low quality. Considering the high and growing incidence of both prostate and bladder cancer, there is an urgent need for economic assessment of a high methodological standard and based on data of a good quality.

Technologic advances in diagnostic imaging have significantly improved the detection and staging accuracy of urologic cancer. Intravenous urography (IVU) is not sensitive for the detection of renal lesions, and a normal IVU does not exclude the presence of renal cancer. At this time, computed tomography (CT) is the method of choice for the detection of renal tumors. Ultrasound (US) can be used for the differentiation of cystic from solid lesions, but CT is more accurate. Magnetic resonance (MR) imaging presently is inferior to CT for the detection of renal lesions. However, in the staging of known renal carcinoma, MR surpasses CT in the staging of large lesions or lesions of stage III and IV disease. In the detection of bladder tumors, cystoscopy and biopsy remain the most accurate diagnostic method. CT and MR imaging are indicated for the staging of bladder neoplasms. Transurethral US shows promise, but is still under investigation. At present, the combination of physical examination, transrectal US, and when needed, US-guided biopsy, are the optimal screening approaches for the detection of prostatic carcinoma. For the staging of diagnosed prostatic carcinoma, MR is superior to CT, but neither is accurate in assessing lymph node involvement. As compared with transrectal US, MRI is superior for the evaluation of extension to the bladder base and seminal vesicles. It is hoped that in the near future, localized tissue MR spectroscopy will be used clinically and will improve the specificity of diagnosis of prostatic carcinoma.

Symptoms, signs, and laboratory findings that indicated excretory urography in 1,622 patients, were compared with the radiographs. The chance that an indication would be associated with demonstrable disease was calculated. No "low-likelihood" indications could be identified. Elimination of the urograms obtained for any of the indications would not have been possible without simultaneously precluding detection of many diseased patients. The monetary cost of case-finding was low, and the efficacy of patient referral high.