The economics of bladder cancer in the US: Increasing costs and unsustainable patterns

Michael S. Cookson, MD, MMHC, FACS

The contemporary management of bladder cancer is both exciting in terms of the explosion in new therapies and improved outcomes and yet highly concerning when considering the financial impact and its reverberations that will amplify over the next decade. There is a growing challenge to the US health care system with respect to treatment and management, affecting both non–muscle-invasive and muscle-invasive disease. There were an estimated 83,190 new cases of bladder cancer in 2024, and after accounting for the economic impact of the care it is one of the costliest cancers to treat per patient.¹ Although medical progress is transforming treatment approaches, these developments carry a significant financial burden. This editorial examines the impact of increasing bladder cancer expenses in the context of the bigger picture of health care expenses and realizing that the existing path is untenable and requires a more strategic, value-based strategy.

Health care expenditures in the US currently represent almost 18% of the gross domestic product (GDP), a number expected to rise in the future.² This percentage is notably greater than those of other developed countries, which generally allocate between 9% and 12% of their GDP for health care. These expenses burden the economy, with escalating costs linked to elements such as an aging demographic, advancements in health care technology, and the widespread occurrence of chronic illnesses such as cancer. In this context, bladder cancer exemplifies a microcosm of the difficulties encountered by the wider health care system: reconciling the demand for innovation with cost-effectiveness and sustainability.

Non–muscle-invasive bladder cancer (NMIBC) represents around 80% of new bladder cancer cases, highlighting the financial strain of this illness. The standard treatment includes transurethral resection of bladder tumor, intravesical BCG therapy, and rigorous monitoring—a protocol that may reach costs of $20,000 each year per patient.³ For the 20% of patients who develop muscle-invasive bladder cancer (MIBC), treatment expenses increase significantly, often surpassing $100,000 per patient each year because of the requirement for radical cystectomy, chemotherapy, and/or immunotherapy.⁴

The recent arrival of new treatments provides optimism for improved results but entails a considerable expense. Pembrolizumab (Keytruda), a PD-1 inhibitor, received approval for NMIBC that does not respond to BCG and led to a 41% complete response (CR) rate at 3 months in the results of the phase 2 KEYNOTE-057 trial (NCT02625961), with lasting responses observed in certain patients.⁵ Nonetheless, the yearly expense for pembrolizumab treatment is around $150,000 for each patient.⁵ In a similar vein, nadofaragene firadenovec (Adstiladrin), a gene therapy administered intravesically that provides interferon alfa-2b, has demonstrated encouraging outcomes in clinical studies, achieving a CR rate of 53.4% at 3 months and 45.5% at 12 months; however, it costs approximately $70,000 per treatment,⁶ and a complete cycle would be 4 treatments over the course of the year.

Additional innovations, like TAR-200, a silicone-derived drug delivery mechanism for prolonged intravesical gemcitabine release, have shown CR rates of 75.7% at 6 months in patients with NMIBC unresponsive to BCG.⁷

These treatments aim to enhance results by lowering recurrence rates and postponing progression, but they may significantly increase the financial strain on the health care system. If 30% of patients with NMIBC select more expensive therapies, this change could raise yearly treatment costs by $50,000 for each patient, contributing billions to total health care spending.

As many as 50% of patients with NMIBC experience a relapse following initial treatment, and 20% progress to MIBC, resulting in a substantial increase in health care expenses due to the requirement for more intensive treatments.⁴ Radical cystectomy, a standard procedure for advanced conditions, is linked to significant morbidity, prolonged hospital stays, and elevated rates of postoperative complications, thereby increasing expenses. Moreover, patients who develop metastatic disease typically need palliative care and costly systemic treatments, like checkpoint inhibitors, which contribute to the overall financial strain.

The increasing expenses associated with bladder cancer treatment highlight wider issues regarding the sustainability of health care expenditures in the US. With health care already accounting for almost one-fifth of GDP, additional growth is likely to shift resources away from other essential areas like education and infrastructure. Additionally, these expenses are unfairly shouldered by patients, employers, and public programs such as Medicare and Medicaid, worsening financial disparities.

New treatments for bladder cancer highlight the clash between innovation and cost-effectiveness. Although innovative therapies provide considerable clinical advantages, their substantial costs prompt concerns regarding accessibility and sustainability in the long run. If existing trends persist, the total 5-year expense of bladder cancer treatment in the US might increase by approximately $20 billion, fueled by both the growing occurrence of the illness and the implementation of costly new treatments. Such an increase is unlikely to be maintainable given the current pressures on the health care system.

To tackle these issues, a transition to value-based care in the management of bladder cancer is crucial. This method emphasizes actions that provide the highest clinical advantage in relation to their cost, guaranteeing efficient allocation of resources. Various approaches may assist in reaching this objective, as follows:

• Health economic assessments: Thorough cost-effectiveness evaluations must be conducted alongside the authorization of new treatments to verify that their implementation is warranted by tangible enhancements in results.

• Risk stratification and enhanced patient selection: Tailored treatment plans that consider tumor biology and individual patient traits may enhance results while reducing unneeded costs.

• Comparative efficacy and sequencing: Additional studies comparing approved agents and more information regarding not only patient selection but sequencing of agents could improve both outcomes and reduce cost.

• Creative payment structures: Partnerships between insurers and drug manufacturers, like value-based pricing or consolidated payments, may assist in lessening the financial burden of expensive treatments.

• Strategies for prevention and early detection: Greater funding for prevention and early identification could lessen the overall impact of bladder cancer by recognizing and addressing the disease in its initial, most treatable state.

• Emphasize quality of life: Cost-effectiveness must consider patient-reported outcomes, guaranteeing that new therapies enhance both survival rates and quality of life.

The management of bladder cancer is at a critical juncture. Although the latest wave of therapeutic breakthroughs presents unparalleled chances to enhance results, the related expenses prompt significant worries regarding long-term viability. Policy makers, health care providers, and industry stakeholders need to collaborate to strike a balance between the necessity for innovation and the requirement for economic accountability. The move toward individualized, value-driven care offers a hopeful direction ahead, yet realizing this vision necessitates fundamental changes in the processes of developing, assessing, and providing therapies.

The US health care system confronts a harsh truth: Without major reforms, the escalating expenses of cancer treatment, such as bladder cancer, will become increasingly untenable. Tackling these challenges will necessitate courageous measures and cooperative approaches that emphasize both clinical superiority and financial responsibility. As we approach a pivotal shift in bladder cancer therapy, our shared duty is evident: to guarantee that the advantages of advancements are available, fair, and enduring for every patient.

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