Research Papers:

Risk-stratified surveillance protocol improves cost-effectiveness after radical nephroureterectomy in patients with upper tract urothelial carcinoma

Masaki Momota _, Shingo Hatakeyama, Hayato Yamamoto, Hiromichi Iwamura, Yuki Tobisawa, Tohru Yoneyama, Takahiro Yoneyama, Yasuhiro Hashimoto, Takuya Koie, Ikuya Iwabuchi, Masaru Ogasawara, Toshiaki Kawaguchi and Chikara Ohyama

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Oncotarget. 2018; 9:23047-23057. https://doi.org/10.18632/oncotarget.25198

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Masaki Momota1, Shingo Hatakeyama1, Hayato Yamamoto1, Hiromichi Iwamura1,2, Yuki Tobisawa1, Tohru Yoneyama3, Takahiro Yoneyama1, Yasuhiro Hashimoto3, Takuya Koie1, Ikuya Iwabuchi4, Masaru Ogasawara4, Toshiaki Kawaguchi4 and Chikara Ohyama1,3

1Department of Urology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan

2Department of Urology, Tohoku Medical and Pharmaceutical University, Sendai, Japan

3Department of Advanced Transplant and Regenerative Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan

4Department of Urology, Aomori Prefectural Central Hospital, Aomori, Japan

Correspondence to:

Shingo Hatakeyama, email: [email protected]

Keywords: upper tract urothelial carcinoma; radical nephroureterectomy; recurrence; surveillance; cost-effectiveness

Received: December 26, 2017     Accepted: April 06, 2018     Published: May 01, 2018


Objectives: To develop a surveillance protocol with improved cost-effectiveness after radical nephroureterectomy (RNU), as the cost-effectiveness of oncological surveillance after RNU remains unclear.

Results: Of 426 patients, 109 (26%) and 113 (27%) experienced visceral and intravesical recurrences, respectively. The pathology-based protocol found significant differences in recurrence-free survival in the visceral recurrence but not in the intravesical recurrence. The medical costs per visceral recurrence detected were high, especially in normal-risk (≤ pT2N0, LVI-, SM-) patients. We developed a risk score associated with visceral recurrence using Cox regression analysis. The risk score-based protocol was significantly more cost-effective than the pathology-based protocol. Estimated cost differences reached $747,929 per recurrence detected, a suggested 55% reduction.

Materials and Methods: We retrospectively evaluated 426 patients with RNU for upper tract urothelial carcinoma (UTUC) without distant metastasis at 4 hospitals. Patients with routine oncological follow-up were stratified into normal-, high- and very high-risk groups according to a pathology-based protocol utilizing pathological stage, lymphovascular invasion (LVI) and surgical margin (SM). Cost-effectiveness of the pathology-based protocol was evaluated, and a risk score-based protocol was developed to optimize cost-effectiveness. Risk scores were calculated by summing up risk factors independently associated with recurrence-free survival. Patients were stratified by low-, intermediate- and high-risk score. Estimated cost per recurrence detected by pathology-based and risk score-based protocols was compared.

Conclusions: A risk score-stratified surveillance protocol has the potential to reduce over investigation during follow-up, making surveillance more cost-effective.

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PII: 25198