High-risk nonmuscle-invasive bladder cancer (NMIBC) treated with bacillus Calmette-Guérin (BCG) is associated with poor oncologic outcomes and high costs, according to a study of veterans with equal access to health care.

Among 412 patients with high-risk NMIBC treated at US Veterans Affairs centers, 95% received induction BCG involving 5 instillations within 70 days, but only 37% continued to maintenance BCG therapy, Stephen B. Williams, MD, MS, of the University of Texas Medical Branch in Galveston, and collaborators reported in JAMA Network Open. At 10 years, progression-free survival and disease-specific death rates were 78% and 92%, respectively.

The presence of carcinoma in situ (Cis) compared with its absence was independently associated with an 85% higher risk for cancer progression and worse 10-year bladder cancer-specific survival (87% vs 94%).

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Further, NMIBC progression was associated with significantly increased costs at 5 years: median $232,729 vs $94,879 with no progression. Outpatient care, pharmacy services, and surgery-related costs during progression drove the increase in medical spending.

In an accompanying editorial, Alejandro Sanchez, MD, and Neeraj Agarwal, MD, of Huntsman Cancer Institute at the University of Utah in Salt Lake City, highlighted key areas for improvement:

“Important initiatives for high-risk NMIBC include assessments of quality and use of initial and second [transurethral resection of bladder tumor], quantification of barriers to use of and adherence to induction and maintenance BCG therapy, and improvement of use of radical cystectomy for appropriately selected patients. These initiatives will help decrease disease progression among this patient population and ultimately help curtail costs.”

Disclosure: This study was supported by Merck Sharp & Dohme Corp. Please see the original references for a full list of authors’ and editorialists’ disclosures.


Williams SB, Howard LE, Foster ML, et al. Estimated costs and long-term outcomes of patients with high-risk non-muscle-invasive bladder cancer treated with bacillus Calmette-Guérin in the Veterans Affairs health system. Published online March 31, 2021. JAMA Netw Open. doi:10.1001/jamanetworkopen.2021.3800

Sanchez A, Agarwal N. Quantifying the costs of care among patients with high-risk non-muscle-invasive bladder cancer treated in the Veterans Health Administration. Published online March 31, 2021. JAMA Netw Open. 2021;4(3):e213816. doi:10.1001/jamanetworkopen.2021.3816