In our recent journal article, we describe outcomes of nonmuscle invasive bladder cancer (NMIBC) patients from an equal-access setting—the United States Veterans Health Administration (VA)—who received BLC. We found that there was a 30% reduction in recurrence risk following BLC (Hazard Ratio [HR] 0.70; 95% Confidence Interval [CI], 0.54-0.90). Though our data contrasts the recent PHOTO trial that found BLC did not reduce recurrence rates compared to WLC, it is important to note that 88% of their cohort were intermediate risk and did not consistently receive BCG treatment, possibly limiting the impact of these findings.6 In our study, we evaluated mostly high-risk NMIBC patients (65% of total cohort) who were treated with BCG. This parallels the 2021 Cochrane review of 15 randomized trials that found BLC may reduce recurrence risk by 34% compared to white light (HR, 0.66; 95% CI, 0.54-0.81) (14).7 Together, these important findings lend further support that BLC may reduce recurrence risk in NMIBC patients.
Further, in a subset analysis, we found no significant difference in recurrence (HR 0.69; 95%CI 0.39-1.20), progression (HR 1.13; 95%CI 0.32-3.96), and overall survival (HR 0.74; 95%CI 0.31-1.77) following BLC by Black and White race. However, given the wide HRs between these groups, one can question whether these findings are truly due to the equal access nature of the VA thereby reducing disparities, or are a consequence of limited power to detect such differences. Thus, larger studies are needed to confirm our findings.
In summary, mitigating recurrence is an unmet need for NIMBC patients as upwards of 60% of these patients have recurrent bladder cancer within 1 year. Our study of a predominately high-risk cohort provides more evidence that BLC may be better than WLC in reducing bladder cancer recurrence risk, which supports current AUA/SUO guidelines recommending BLC usage in patients with NMIBC to increase detection and decrease recurrence.
Written by:
- Sanjay Das, MD, Department of Urology, University of California - Los Angeles, Los Angeles, CA
- Stephen B. Williams, MD, MBA, MS, FACS Associate Chief Medical Officer UTMB Clear Lake Medical Director for High Value Care UTMB Health System, Houston, TX
- Fradet Y, Grossman HB, Gomella L, et al. A comparison of hexaminolevulinate fluorescence cystoscopy and white light cystoscopy for the detection of carcinoma in situ in patients with bladder cancer: a phase III, multicenter study. J Urol. Jul 2007;178(1):68-73; discussion 73.
- Rink M, Babjuk M, Catto JW, et al. Hexyl aminolevulinate-guided fluorescence cystoscopy in the diagnosis and follow-up of patients with non-muscle-invasive bladder cancer: a critical review of the current literature. Eur Urol. Oct 2013;64(4):624-38.
- Naselli A, Introini C, Timossi L, et al. A randomized prospective trial to assess the impact of transurethral resection in narrow band imaging modality on non-muscle-invasive bladder cancer recurrence. Eur Urol. May 2012;61(5):908-13.
- Geavlete B, Multescu R, Georgescu D, Jecu M, Stanescu F, Geavlete P. Treatment changes and long-term recurrence rates after hexaminolevulinate (HAL) fluorescence cystoscopy: does it really make a difference in patients with non-muscle-invasive bladder cancer (NMIBC)? BJU Int. Feb 2012;109(4):549-56.
- Enhanced Visualization Methods for First Transurethral Resection of Bladder Tumour in Suspected Non-muscle-invasive Bladder Cancer: A Health Technology Assessment. Ont Health Technol Assess Ser. 2021;21(12):1-123.
- Heer R, Lewis R, Vadiveloo T, et al. A Randomized Trial of PHOTOdynamic Surgery in Non–Muscle-Invasive Bladder Cancer. NEJM Evidence. 2022/09/27 2022;1(10)
- Maisch P, Koziarz A, Vajgrt J, Narayan V, Kim MH, Dahm P. Blue versus white light for transurethral resection of non-muscle invasive bladder cancer. Cochrane Database Syst Rev. Dec 1 2021;12(12)