Underutilization of Blue Light Cystoscopy for Bladder Cancer in the United States - Beyond the Abstract

Blue light cystoscopy (BLC) for the management of non-muscle invasive bladder cancer (NMIBC) is an evidence- and guideline-supported intervention that has been shown to increase cancer detection and decrease recurrence.

That considered, there are practical limitations to the use of BLC including the availability of technology and peri-operative patient workflow that includes catheterization and instillation of hexaminolevulinate, the active compound that is preferentially taken up by rapidly dividing cancer cells and then visualized using blue light. Real-world practice patterns are difficult to assess, as survey data has a strong academic bias and claims databases may not accurately capture its use. Additionally, the application of other evidence-based interventions in NMIBC such as post-transurethral resection of bladder tumor (TURBT) intravesical chemotherapy is notoriously low, and therefore, BLC practice patterns are of particular interest.

We studied the use of BLC amongst patients with bladder cancer undergoing TURBT in the Premier Healthcare Database (Premier) from January 2011 (corresponding to the first use of BLC in this dataset) to March 2020. Premier captures all-payer encounter and billing-level data from hospitals (including inpatient, ambulatory surgery, and other settings) across all United States census regions. The dataset includes itemized billing information, allowing for the identification of hexaminolevulinic acid administration as a proxy for BLC. 

Overall BLC use was low amongst the study cohort. Although rates increased following a recommendation in the American Urological Association guideline on NMIBC in 2016, a maximum of 1.8% of all TURBTs was performed with BLC. This percentage was 9.9% amongst hospitals with demonstrated BLC capacity (evidenced by any previous use of BLC at that hospital). 

More specifically, hospital-level acquisition of BLC capability increased throughout the entire study period, reflected in the fact that more and more distinct hospitals performed BLC through March 2020. This growth was counteracted by stagnation and then a decline (starting in mid-2018) in the proportion of providers using BLC at hospitals with BLC capability.  

To focus on this concerning provider-level trend, we also identified surgeon characteristics associated with complete BLC omission. To control for technology availability, only surgeons operating at hospitals with BLC capability were included in this sub-analysis. Intuitively, lower surgeon TURBT volume, low surgeon radical cystectomy volume, and complete omission of post-operative intravesical chemotherapy were significantly associated with never using BLC. 

Overall, our findings demonstrated a concerning, low level of BLC use despite guideline recommendations and evidence, including cost analyses, demonstrating its utility. In particular, low-volume surgeons who did not follow other evidence-based practices were less likely to use BLC. Our work suggests significant room for improvement in population-level bladder cancer outcomes, and this may be facilitated by better understanding factors leading particular providers to forgo BLC use. 

Written by: Patrick Lewicki, MD, Department of Urology, New York-Presbyterian Hospital, Weill Cornell Medicine, New York, NY

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