SUO 2017: Cost-Consequence Analysis of Blue Light Cystoscopy with Hexaminolevulinate in Non-Muscle Invasive Bladder Cancer

Washington, DC (  Blue light cystoscopy (BLC) utilizing pre-administered hexaminolevulinate (HAL) has been increasingly gaining recognition as an adjunct to standard white light cystoscopy (WLC) for the identification of difficult to recognize bladder pathology, such as low volume non-muscle-invasive bladder cancer (NMIBC) and carcinoma in situ (CIS). Its utilization in the setting of transurethral resection of bladder tumour (TURBT) for NMIBC has been demonstrated to reduce recurrence and progression, though often in select centers with expertise in NMIBC management. Per the authors of the study, these studies have used 'best case scenario' recurrence rate probabilities, thus decreasing the generalizability of the findings.

In the setting of increased health care expenditures, we have to further analyze each novel technology from a standpoint of cost effectiveness. To that effect, the authors completed contemporary cost-effectiveness assessment of BLC compared to WLC at the time of TURBT. They generated a decision and cost-effectiveness model with a five-year time horizon following initial TURBT; the model was created from the healthcare payer perspective. They used a meta-analysis of contemporary recurrence and progression rates. Recurrence relative risk (RR) was 076 for BLC+HAL vs. WLC. A decision model adapted from the UK’s National Healthcare System (NHS). Cost variables included in the model were from three large Canadian bladder cancer centers. Primary outcomes were number of recurrences prevented, bed days saved, and overall costs.

Their key findings:

  1. Variable cost from province to province. The five-year cost of using BLC with HAL on all incident NMIBC compared to WLC assistance was $4,832,908 for Ontario (n=4696; $1372/patient); $1,168,968 for British Columbia (n=1204; $1295/patient); and $2,484,872 (n=2680; $1236/patient) for Quebec
  2. Use of BLC with HAL would result in 87,338 fewer recurrences annually. On sensitivity/scenario analyses for Ontario data, if BLC with HAL equipment were provided to the province at no cost, five-year costs would be $4,158 814 and $1181 cost per patient
  3. If BLC with HAL were only used for cystoscopically appearing aggressive tumors, the five-year amortized cost in Ontario would be $3,874,098, with a cost per patient of $1222
  4. If there was a 20% or 50% improvement in progression rates with BLC plus HAL, the five-year amortized cost would be $2,660,529 and -$598,039 (cost-saving), respectively.
Based on these results, the authors concluded that TURBT using BLC with HAL for patients with NMIBC is associated with a five-year cost of approximately $1-5 million for jurisdictions of 4-13 million people in the Canadian health care system. Although this translates to a cost of $1200-1400 per patient for their initial TURBT, BLC with HAL improves patients care, reduces recurrences, and decreases the need for hospital beds after TURBT. In addition, with reduction in progression, it may translate to reduced need for cystectomy or other more significant interventions.

Limitations / Discussion Points:

  1. Limited to Canadian cancer centers – a nationalized health care system. The costs are not generalizable to other health care systems.
  2. The data does not necessarily account for reduced cost of interventions such as cystectomy, chemotherapy, or radiation for patients that would no longer progress to muscle invasive therapy.
Presented by: Zachary Klaassen MD 

Co-Authors: Kathy Li MPH, Wassim Kassouf MD, Peter C. Black MD, Alice Dragomir MSc, PhD and Girish S. Kulkarni MD, PhD, University of Toronto  

Written by: Thenappan Chandrasekar, MD, Clinical Fellow, University of Toronto, Twitter: @tchandra_uromd at the 18th Annual Meeting of the Society of Urologic Oncology, November 20-December 1, 2017 – Washington, DC