One risk factor for recurrence is incomplete resection at initial TURBT. In order to improve visualization, hexaminolevulinate (HAL) hydrochloride (Photocure®, Oslo, Norway) has been used with blue light cystoscopy (BLC) for aiding detection of non-muscle invasive bladder cancer (NMIBC). Several RCTs have reported improvements in NMIBC recurrence rates using BLC with HAL; however, widespread adoption varies because of equipment availability and cost constraints.2
Previous cost-effectiveness studies have shown cost savings using BLC with HAL, however these studies often use ‘best case scenario’ recurrence rate probabilities. Dr. Klaassen presented a study aiming to provide the first decision analysis using updated, meta-analyzed probabilities for risk of recurrence (BLC with HAL TURBT vs white light cystoscopy (WLC) TURBT) at the population level.
A systematic review was performed using PRISMA guidelines to ultimately include 33 studies in the decision-tree analysis - 10 were RCTs of BLC with HAL vs WLC that were used to meta-analyze sensitivities and specificities. Burger et al. used raw data of RCTs to meta-analyze recurrence relative risk (RR) for BLC with HAL vs WLC assisted TURBT, and this RR (0.761) was used in the baseline decision-tree analysis.3
A decision model created and used by the UK’s NHS system was adapted to assess the cost-effectiveness of BLC with HAL-assisted vs. conventional WLC-assisted TURBT for patients with suspected new or recurrent NMIBC. The authors assumed a NMIBC rate of 75%. Micro-costing data were obtained from three academic teaching hospitals from Ontario, British Columbia (BC), and Quebec.
Results showed that the 5-year amortized cost of using BLC with HAL on all incident NMIBC compared to WLC assistance was $4,832,908 for Ontario (n=4,696; $1,372/patient); $1,168,968 for BC (n=1,204; $1,295/patient); and $2,484,872 (n=2,680; $1,236/patient) for Quebec. On sensitivity/scenario analyses for Ontario data, if BLC with HAL equipment were provided to the province at no cost, 5-year costs would be $4,158,814 and $1,181 cost per patient. If BLC with HAL were only used for cystoscopically appearing aggressive tumours, the 5-year amortized cost would be $3,874,098, with a cost per patient of $1,222. If there was a 20% or 50% improvement in progression rates with BLC plus HAL, the 5-year amortized cost would be $2,660,529 and -$598,039 (cost-saving), respectively.
In summary, TURBT using BLC with HAL for patients with NMIBC is associated with a 5-year cost of approximately $1-5 million for jurisdictions of 4-12 million people. Although this translates to a cost of $1200-1400 per patient for initial TURBT, BLC with HAL improves patient care, reduces recurrences, and decreases the need for hospital beds after TURBT. If this diagnostic procedure ultimately improves progression rates, cost effectiveness would be improved as well.
Presented By: Zachary Klaassen, MD, University of Toronto/Princess Margaret Cancer Centre, Toronto, Ontario, Canada
Written By: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre Twitter: @GoldbergHanan at the 72nd Canadian Urological Association Annual Meeting - June 24 - 27, 2017 - Toronto, Ontario, Canada
1. Avritscher EB, Cooksley CD, Grossman HB, et al. Urology 2006;68:549-553.
2. Witjes JA, Babjuk M, Gontero P, et al. Eur Urol 2014;66:863-871.
3. Burger M, Grossman HB, Droller M, et al. Eur Urol 2013;64:846-854.