Blue Light Cystoscopy Associated With Lower Risk of Recurrence of NMIBC

Bladder cancer with organs and cancerous cells: matthieu - stock.adobe.com

Patients who received blue light cystoscopy (BLC) had significantly lower risk of recurrence of non–muscle invasive bladder cancer (NMIBC) at 3 years compared with those who received white light cystoscopy (WLC) to aid transurethral resection of bladder tumor (TURBT), according to findings published in JU Open Plus.¹

Investigators in the BRAVO study (Bladder Cancer Recurrence Analysis in Veterans and Outcomes) performed a retrospective analysis of patients in the Veterans Affairs Healthcare System. At median follow-up of 3.7 years, there was a 38% reduction of recurrence at 3 years (HR, 0.62; 95% CI, 0.45-0.86; P < .01) in those who received BLC vs WLC.

“In this propensity-score matched cohort study, we found that the use of BLC vs WLC alone was associated with significantly decreased 38% risk of recurrence. Our results are in line with the recent Cochrane review of nearly 3000 patients across 15 randomized trials, where the authors found that that BLC may reduce the risk of bladder cancer recurrence by 34%,” said Steven Williams, MD, MBA, MS, professor and chief of the division of urology at the University of Texas-Medical Branch, and one of the study authors, in a press release from Photocure ASA.²

BLC with the photosensitizer hexyl aminolevulinate can enhance detection of lesions and their margins, but WLC continues to be used as standard of care in pathologic diagnosis and staging of NMIBC. The BRAVO study offers data from a real-world equal access setting, looking at patients treated from 1997 to 2023.¹

The study included 2 cohorts, one which consisted of 348 patients with NMIBC who had received BLC at any point, and the other which consisted of 392 who had received only WLC. Propensity score matching resulted in 313 patients from each cohort being matched based on baseline demographics and clinical variables. Cox proportional hazard regressions were conducted with an unadjusted analysis and a multivariate adjusted for baseline covariates including age at diagnosis, sex, race (non-Black vs Black), ethnicity (Hispanic vs non-Hispanic), location of diagnosis (at a Veterans Affairs center vs at a non- Veterans Affairs facility), smoking status (ever vs never), disease risk (low vs high), and time-dependent covariates (intravesical BCG and intravesical chemotherapy).

The majority of patients in this study population had high-risk NMIBC (n = 381, 61%). The median age at diagnosis was 71 years, 90% were non-Black and 97% were non-Hispanic, and 82% were smokers. Across both cohorts, 56% received intravesical BCG (Bacillus Calmette Guérin vaccine) with significantly more receiving BCG in the BLC group vs the WLC group (61% vs 43%, respectively). Definitive treatment was given in 8% with BLC and 6% with WLC.

Among the 626 patients, 159 (25%) had recurrence of bladder cancer with 64 (20%) in the BLC group and 95 (30%) in the WLC group. The 3-year rate of recurrence-free survival was 74.9% with BLC vs 66.9% with WLC. There was no association found between the risk of recurrence and the use of intravesical BCG or chemotherapy in patients.

High-risk disease status based on T1 staging, carcinoma in situ, or pTa high-grade tumors was strongly associated with recurrence (HR, 2.25; 95% CI, 1.53-3.32), and age was a risk factor as well (HR, 1.31; 95% CI, 1.09-1.59) for every 10 years of age.

There were 38 reported cases of disease progression, 17 (5%) in the BLC group and 21 (7%) in the WLC group. A multivariate adjusted analysis showed a HR for progression of 0.71 favoring BLC (95% CI, 0.37-1.38) but this was not statistically significant. Progression was also not associated with use of intravesical BCG or chemotherapy, age, sex, race, ethnicity, or smoking status. High-risk disease was associated with increased risk of progression (HR, 4.44; 95% CI, 1.49-13.25).

A subanalysis was performed on the role of BLC in reducing risk of undergrading NMIBC; BLC detected higher-grade NMIBC in 33 patients compared with 9 for WLC (HR, 1.92; 95% CI, 1.23-3.02).

In an editorial comment published in response to the study, it was noted that the increased use of intravesical therapies in the BLC group could be a consequence of enhanced tumor detection allowing for more precise risk stratification and better therapeutic decision-making.³ The lack of significant progression-free survival benefit despite using a cohort with more high-risk patients than other comparable studies suggests a need for studies with larger cohorts, as the rate of progression was low in this cohort.^1,3

“These data support current [American Urological Association/Society of Urologic Oncology] guidelines recommending BLC usage in patients with NMIBC to increase detection and decrease recurrence,” stated Williams.²

_References:

_{1. Nasrallah AA, Das S, Evans C, et al. Oncologic outcomes of blue light cystoscopy in an equal access setting: results of the BRAVO study. JU Open Plus. 2025;3(3):e000017. doi:10.1097/JU9.0000000000000260}

_{2. New BRAVO study publication reinforces clinical benefits of BLC in reducing risk of bladder cancer recurrence. News release. Photocure. March 14, 2025. Accessed March 24, 2025. https://www.prnewswire.com/news-releases/new-bravo-study-publication-reinforces-clinical-benefits-of-blc-in-reducing-risk-of-bladder-cancer-recurrence-302401805.html}

_{3. Aliaga A, Fernández MI. Editorial comment: oncologic outcomes of blue light cystoscopy in an equal access setting: results of the BRAVO study. JU Open Plus. 2025;3(3):e000018. doi:10.1097/JU9.0000000000000265}