(UroToday.com) The 2025 EAU annual meeting featured a non muscle invasive bladder cancer session and a presentation by Dr. Amanda Myers discussing cost-effectiveness analysis of treatments for BCG-unresponsive high-risk non muscle invasive bladder. Since 2021, the FDA has approved three therapies: pembrolizumab, nadofaragene firadenovec, and nogapendekin alfa inbakicept for patients with "BCG-unresponsive" disease.
With no head to head comparison of treatments, counseling patients on choice and sequence of therapies will depend on efficacy, tolerability as well as cost. At the 2025 EAU annual meeting, Dr. Myers and colleagues presented results of a cost-effectiveness analysis of these treatments.
This analysis examined patients with BCG-unresponsive bladder cancer, the definition as established by the FDA. A Markov decision analytic model was created for a 70-year-old male with BCG-unresponsive CIS:
Five treatments were assessed:
- Radical cystectomy
- Nadofaragene
- Nogapendekin/BCG
- Pembrolizumab
- Gemcitabine + docetaxel
Efficacy and tolerability data were based on clinical trials and published reports. Cost-effectiveness was assessed over a 5-year time horizon using a willingness-to-pay threshold of $100,000 USD per quality-adjusted life-year from the 2024 US Medicare payer perspective. Additional sensitivity analyses were performed.
To replicate real world situations, 3 index patients were developed. For index patient 1, willing to undergo a radical cystectomy or 1 line of therapy prior to radical cystectomy, gemcitabine + docetaxel was the most cost-effective, followed by radical cystectomy, pembrolizumab, nadofaragene, and nogapendekin/BCG:
For index patient 2, who is willing to undergo upfront radical cystectomy or up to 2 lines of therapy, radical cystectomy was the most cost-effective strategy, following by gemcitabine + docetaxel, pembrolizumab, nadofaragene, and nogapendekin/BCG:
For index patient 3, who declines radical cystectomy unless treated with 1-2 lines of an FDA-approved treatment first, pembrolizumab was the most cost-effective, followed by nadofaragene and nogapendekin/BCG:
Dr. Myers concluded her presentation discussing cost-effectiveness analysis of treatments for BCG-unresponsive high-risk non muscle invasive bladder with the following take home points:
- Current pricing of bladder sparing treatments presents significant financial challenges, underscoring the need for better treatment selection tools and more equitable pricing
- These data are sobering and highlight the need to evaluate strategies to reduce cost simultaneously with improved patient selection to enhance efficacy
Written by: Zachary Klaassen, MD, MSc – Urologic Oncologist, Associate Professor of Urology, Georgia Cancer Center, Wellstar MCG Health, @zklaassen_md on Twitter during the European Association of Urology (EAU) 2025 Annual Meeting, Madrid, Spain, Fri, Mar 21 – Mon, Mar 24, 2025.