According to the AUA/SUO Guideline on the diagnosis and treatment of NMIBC, a complete TURBT is critical in the management of NMIBC for accurate tumor type, staging, grading, and optimization of patient outcomes1. The guidelines state that in a patient with NMIBC, a clinician should offer blue light cystoscopy at the time of TURBT, if available, to increase detection and decrease recurrence (Moderate recommendation, Grade B). Furthermore, in a patient with a history of NMIBC with normal cystoscopy and positive cytology, a clinician should consider a prostatic urethral biopsy and upper tract imaging, as well as enhanced cystoscopic techniques (blue light cystoscopy, when available), ureteroscopy, or random bladder biopsies (Expert Opinion).
Why do guidelines recommend blue light cystoscopy? According to Dr. Lotan, there is improved detection of tumors, especially CIS (strong evidence), as well demonstration of reduction in recurrence (strong evidence). Furthermore, there is weak evidence (but improving) that there are lower progression rates. With regards to the outpatient setting, he notes that with white light cystoscopy only, there is a possibility of missing papillary tumors and CIS. The implications of this are that there is a delay in diagnosis and possibly disease progression.
Dr. Lotan was part of a phase III comparative, multi-center study assessing the safety of blue light flexible cystoscopy with hexaminolevulinate (HAL) in surveillance of bladder cancer patients2. The primary endpoint of this study (n=304) was the proportion of patients with histologically confirmed malignancy detected only with blue light flexible cystoscopy. Following surveillance, 103 of the 304 patients were referred, including 63 with confirmed malignancy, of whom 26 had CIS. In 13 of the 63 patients (20.6%) recurrence was seen only with blue light flexible cystoscopy (p <0.0001); five cases were confirmed as CIS. Operating room examination confirmed CIS in 26 of 63 patients (41%), which was detected only with blue light cystoscopy in 9 of the 26 (34.6%, p <0.0001). Blue light cystoscopy identified additional malignant lesions in 29 of the 63 patients (46%). The false-positive rate was 9.1% for white and blue light cystoscopy.
A subsequent consensus panel had the following recommendations for best practice:
- A strong recommendation for the value of blue light cystoscopy at initial 3-month cystoscopy for AUA intermediate and high-risk patients
- Most recommended blue light cystoscopy at 3 and 6 months and then every 6 months for high-risk patients in the first two years
- Most recommended use prior to intravesical therapy if there is a concern for residual disease after TURBT
- Most recommended for use at the time of office and/or biopsy for low-grade tumors
- Blue light cystoscopy may have a role in evaluating patients with a positive cytology or equivocal lesions on white-light cystoscopy
Dr. Lotan provided the following algorithm with respect to timing and utilization of blue light cystoscopy:
In conclusion, Dr. Lotan provided several key messages:
- Blue light cystoscopy improves the detection of patients with recurrent bladder cancer (20.6%)
- Blue light cystoscopy significantly improves the detection of patients with CIS (34.6%)
- Tumor detection was improved in 46% of patients who underwent repeat blue light cystoscopy
- Patients found the procedure worthwhile
- Several future needs include assessing whether low and intermediate risk patients will benefit from blue light cystoscopy, how often it should be performed, and analyzing cost-effectiveness models
Written By: Zachary Klaassen, MD, MSc – Assistant Professor of Urology, Georgia Cancer Center, Augusta University - Medical College of Georgia, @zklaassen_md at American Urological Association's 2019 Annual Meeting (AUA 2019), May 3 – 6, 2019 in Chicago, Illinois
- Chang SS, Boorjian SA, Chou R, et al. Diagnosis and treatment of non-muscle invasive bladder cancer: AUA/SUO Guideline. J Urol 2016;196(4):1021-1029.
- Daneshmand S, Patel S, Lotan Y, et al. Efficacy and safety of blue light flexible cystoscopy with hexaminolevulinate in the surveillance of Bladder Cancer: A Phase III, Comparative, Multicenter Study. J Urol 2018 May;199(5):1158-1165.