Contemporary cost-consequence analysis of blue light cystoscopy with hexaminolevulinate in non-muscle-invasive bladder cancer

Introduction: Previous studies have suggested cost-savings using blue light cystoscopy (BLC) with hexaminolevulinate (HAL) compared to white light cystoscopy (WLC) during transurethral resection of bladder tumour (TURBT) for non-muscle-invasive bladder cancer (NMIBC), secondary to improvements in recurrence and progression rates; however, these studies have used 'best case scenario' recurrence rate probabilities, thus decreasing generaliz-ability of the findings. The objective of this study was to perform a contemporary cost-effectiveness assessment of BLC compared to WLC at the time of TURBT. Methods: A decision and cost-effectiveness model with a five-year time horizon following initial TURBT was used. The model was created from the healthcare payer perspective. Comprehensive literature review was performed to obtain contemporary recurrence and progression rates. These values were meta-analyzed for inclusion into the model. Cost variables included in the model were from three large Canadian bladder cancer centres. Model outputs were number of recurrences prevented, bed days saved, and overall costs. One-way sensitivity and scenario analyses were performed to assess model robustness. Results: The five-year amortized cost of using BLC with HAL on all incident NMIBC compared to WLC assistance was $4 832,908 for Ontario (n=4696; $1372/patient); $1 168 968 for British Columbia (n=1204; $1295/patient); and $2 484, 872 (n=2680; $1236/patient) for Quebec. Use of BLC with HAL would result in 87. 338 fewer recurrences annually. On sensitivity/scenario analyses for Ontario data, if BLC with HAL equipment were provided to the province at no cost, five-year costs would be $4 158 814 and $1181 cost per patient. If BLC with HAL were only used for cystoscopically appearing aggressive tumours, the five-year amortized cost would be $3 874 098, with a cost per patient of $1222. If there was a 20% or 50% improvement in progression rates with BLC plus HAL, the five-year amortized cost would be $2 660 529 and -$598 039 (cost-saving), respectively. Conclusions: TURBT using BLC with HAL for patients with NMIBC is associated with a five-year cost of approximately $1-5 million for jurisdictions of 4-13 million people. Although this translates to a cost of $1200-1400 per patient for their initial TURBT, BLC with HAL improves patients care, reduces recurrences, and decreases the need for hospital beds after TURBT. If this diagnostic procedure eventually improves progression rates, there would be considerably improved cost-effectiveness.