Non-muscle invasive bladder cancer treatment selection in an emerging treatment era: A patient preference study.

Abstract

754 Background: Patients with non-muscle invasive bladder cancer (NMIBC) who become unresponsive to Bacillus Calmette-Guérin (BCG) face preference-sensitive choices between emerging and established bladder-sparing treatments or radical cystectomy (RC). This study elicited 1) the preferences of patients in the United States for bladder-sparing treatments with different benefits and burdens and 2) their choice between these options and RC. Methods: Patients with self-reported NMIBC and BCG experience completed an online survey. A discrete-choice experiment (DCE) elicited preferences for hypothetical bladder-sparing treatments. Evidence-based treatment attributes (and levels) included chance of recurrence of NMIBC (45%-69%) and chance of progression to MIBC 1 year after treatment (2%-30%); administration burden (intravesical every week depending on response or every 3 months for 1 year, or intravenous every 6 weeks for up to 2 years); treatment-related fatigue (none to moderate-severe); chance of discomfort and pain or urinary tract infection (0%-30%); and chance of developing immune-related adverse events (AEs) (0%-25%). Conditional relative importance of attributes and risk tolerance measures were calculated from random parameter logit models. In addition to the DCE, direct-elicitation questions offered choices between fixed profiles of different bladder-sparing treatments and RC. The Shared Decision Making (SDM) Questionnaire (SDM-Q-9) revealed patients’ levels of satisfaction with previous real-world choices. Responses to the fixed-profile questions and SDM-Q-9 were analyzed descriptively. Results: Among the 206 respondents, reduced risks of progression and disease recurrence were the most important attributes given the range of levels included in the DCE. The other attributes—treatment-related AEs and administration burden—were less important and had statistically similar impacts on choices. On average, patients were willing to accept a >25% risk of immune-related side effects requiring oral steroids to achieve the greatest reductions in disease progression and recurrence offered in the survey. With the exception of repeated BCG-like therapy, most patients (>70%) preferred bladder-sparing treatments over RC. Over 25% of respondents disagreed with the statement “My doctor asked me which treatment option I prefer” when reflecting on their SDM experiences. Conclusions: Patients with NMIBC cared most about treatment efficacy and were generally willing to accept clinically relevant levels of treatment-related risks and discomfort to achieve reductions in disease progression and recurrence. Patients demonstrate heterogeneous preferences, and continued efforts to incorporate shared decision-making into treatment decisions are warranted.