Case 1: Use of Blue Light Cystoscopy in Bladder Cancer

EXPERT PERSPECTIVE VIRTUAL TUMOR BOARD

Arlene O. Siefker-Radtke, MD:With blue light, are you able to detect papillary lesions better, or is it most helpful for carcinoma in situ, which sometimes is, at least to my understanding, less easily detected on a routine cystoscopy?

Gordon Brown, DO:It’s actually both, Arlene. When we look at the data, there’s a meta-analysis that was published by Dr Maximilian Burger in 2013 in theEuropeanJournalofUrology,which looked at the prospective trials, 6 of which were run and included in that meta-analysis. And they took that data and they found that white light alone misses about 24% of papillary tumors, and this is about 27% of carcinoma in situ. So the addition of blue light cystoscopy as an adjunct to white light cystoscopy dramatically increases the sensitivity of that diagnosis. And that allows us to do a more complete resection and allows us to make sure as best as possible those patients are visually NED [no evidence of disease] prior to the institution of intravesical therapy.

Also in the setting of patients who have T1 disease, for example, if we go back and do a re-resection, which we routinely do for those patients who have high-grade T1 disease, it allows us to ensure at the time that our resection is complete, again making sure maximal therapy locally has been achieved.

Arlene O. Siefker-Radtke, MD:It sounds like the blue light cystoscopy is a real advantage. Is that used often across the United States, or is it a technology that has limitations, whether it’s cost or access to care?

Gordon Brown, DO:It is a technology that I think changes the way that we manage bladder care patients, potentially both in the diagnosis as well as the surveillance of this patient population. However, the widespread use of this has some challenges, frankly, with respect to the adoption of it. Specifically, the logistics of having this instilled and having these patients undergo blue light surveillance is a little bit challenging, even though it’s FDA approved in the office setting. 2) There are upfront costs associated with it, which makes widespread adoption somewhat challenging, especially in smaller urology clinical settings. As we see this technology become more widely accessed, I think that hopefully the price points will come down and the logistics will be a little bit more efficient to allow patients to access this technology in order to appropriately diagnose and stage them.

Arlene O. Siefker-Radtke, MD:I believe a lot of academic centers use it. I’ve heard our urologists using blue light. How about you, Betsy, are you using it at Fox Chase Cancer Center?

Elizabeth R. Plimack, MD:Our urologists are using it at Fox Chase, and I think it’s a tool like any other. It is helpful in certain circumstances, but it’s not the only tool that they use when evaluating a bladder cancer patient.

Arlene O. Siefker-Radtke, MD:And how about you, Tian?

Tian Zhang, MD:I think we agree. At Duke Cancer Institute our urologists also use this in the operating room.

Arlene O. Siefker-Radtke, MD:OK. So it sounds like the academic centers have it, but we’re still waiting for the community urologists, due to a variety of reasons, to have access to this new technology that’s helpful for our patients. Clearly, if you can start detecting new lesions, that might even impact how you think about previous trial end points from other trials. A trial of BCG [bacillus Calmette-Guérin] and BCG failures that had lower recurrence might now have a higher recurrence. Is that impacting clinical trials that are ongoing today?

Gordon Brown, DO:The answer is yes. Ashish Kamat, MD, obviously looked at just this question. And he, with a consortium of bladder cancer experts, redefined how we consider the BCG-refractory/relapsed continuum with more contemporary definitions of specifically stage progression of disease early on. For example, those patients who had Ta high-grade disease now, within 3 months, if they were to have T1 high-grade disease, obviously that would be a BCG-refractory type patient.

So, looking back on those studies retrospectively, I think imposing that new definition is helpful in reevaluating both our previous studies, but more importantly it allows us to level set a very well defined definition of where we’re going for our contemporary studies and studies to be held in the future. Because now we all agree on a specific definition as it relates to progression of disease in that BCG setting. It allows us a framework in which we can work more effectively and better interpret the data as they come through.

Transcript edited for clarity.