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Bladder Cancer Detection

Curated by Clinicians: Educational Forum with Videos, Abstracts and Conference Information
Videos
From Science to Clinical Utility: Cxbladder Monitor - Bladder Cancer Surveillance for Patients with Urothelial Carcinoma - Tamer Aboushwareb, Neal Shore & Josh Meeks
Blue Light Powered by Saphira® for the Detection of Non Muscle-Invasive Bladder Cancer - Max Kates & Trinity J. Bivalacqua
From Science to Clinical Utility: Cxbladder Detect - Bladder Cancer Detection for Patients Who Present with Hematuria - Tamer Aboushwareb, Neal Shore & Josh Meeks
Realities of Bladder Cancer In Women - Sima Porten, Kristen Scarpato, Svetlana Avulova & Anne Schuckman
Treating Women with Bladder Cancer and a Community Approach to Navigating a Diagnosis - Jeannie Hoffman-Censits & Elizabeth Guancial
Role of Blue Light Cystoscopy in Detecting Invasive Bladder Tumor - Sia Daneshmand
Demonstrated Underuse of Blue Light Cystoscopy for Bladder Cancer in the United States - Patrick Lewicki
Intravesical Therapy for Non-Muscle Invasive Disease - Michael O’Donnell
Variables Associated with the Use of Blue Light Cystoscopy Journal Club - Christopher Wallis & Zachary Klaassen
The Association of Smoking Status with Recurrence in Patients with Predominantly High-Risk Recurrent NMIBC - Richard Matulewicz
Value Based Care in Surveillance of Non-Muscle Invasive Bladder Cancer – Stephen Williams
Update on Urine Markers for Hematuria and Bladder Cancer - Yair Lotan
The Use of Blue Light Cystoscopy for Both Hospital and Outpatient Clinic - Yair Lotan and Daniel Parker
Improved Tumor Visibility, Detection Rate and Reduced Recurrence Rates After TURBT - Siamak Daneshmand and Marek Babjuk
DNA Based Markers in High-risk Non-Muscle Invasive BCG Unresponsive Bladder Cancer - Alexander Wyatt
Pembrolizumab in High-Risk, BCG Unresponsive Non-Muscle Invasive Bladder Cancer - Arjun Balar
Blue Light Cystoscopy with Cysview®: Tips and Tricks - Anne Schuckman
Macro and Microeconomics of Blue Light Cystoscopy with CYSVIEW® in Non-Muscle Invasive Bladder Cancer - Stephen Williams
Management of High-Grade T1 Bladder Cancer: Cystectomy versus BCG - Bernard Bochner & Paolo Gontero
A Discussion on Implementing the Treatment of Non-Metastatic Muscle-Invasive Bladder Cancer AUA/ASCO/ASTRO/SUO Guidelines - Sam Chang
Blue Light Cystoscopy with Cysview® & Adjuvant Perioperative Chemotherapy for Nonmuscle-Invasive Bladder Cancer - Sia Daneshmand & Trinity Bivalacqua
Role of Blue Light Cystoscopy in Bladder Cancer Management - Trinity Bivalacqua
Weathering the Current BCG Shortage Crisis - Michael O’Donnell
Blue Light Cystoscopy with Cysview for Management of Non Muscle Invasive Bladder Cancer - Joshua Meeks
Implications of the Bacillus Calmette-Guérin (BCG) Shortage - Joshua Meeks
Alternative Strategies to Deliver Bladder Cancer Investigation During COVID-19 and Beyond - Neal Shore
Current and Emerging Therapies for Non-Muscle Invasive Bladder Cancer after BCG - Chris Wallis & Zach Klaassen
Pembrolizumab in the BCG-unresponsive NMIBC Patients - Arjun Balar
Utilizing Change Management for Successful Implementation of Blue light cystoscopy (BLC™) - Rebecca Roe
Evaluation of Cxbladder and Adjudication of Atypical Cytology and Equivocal Cystoscopy - Badrinath Konety
Consensus Statement on Flexible Blue Light Cystoscopy (BLC™) with Cysview® - Yair Lotan
Journal Club: The Evaluation of Cxbladder and Adjudication of Atypical Cytology - Sia Daneshmand
Blue Light Cystoscopy with CYSVIEW: Improving Detection Rates of Bladder Cancer in the Clinic - Yair Lotan
Blue Light Cystoscopy (BLC™): What Urologist Want to Know - Anne Schuckman
Blue Light Cystoscopy with Cysview® in the Surveillance of Bladder Cancer - Sia Daneshmand
Efficacy and Safety of Flexible BLC with Cysview® in the Surveillance of Bladder Cancer - Sia Daneshmand
Patient Reported Outcomes in the Use of Blue Light Cystoscopy in the Surveillance of Bladder Cancer - Angela B. Smith
Blue Light Cystoscopy for Diagnosis of Bladder Cancer - A Journal Club Review by Badrinath Konety
Evolution of Technology and Technique in Bladder Cancer - Ashish Kamat
Publications
Articles and Abstracts

Management of non-muscle-invasive bladder cancer (NMIBC) significantly impacts healthcare resource utilization due to requirements for ongoing surveillance. White light cystoscopy (WLC) represents the traditional approach to NMIBC disease surveillance, though physicians utilizing WLC alone may fail to detect all cancerous lesions.

Reno, Nevada (UroToday.com) -- Photocure ASA, The Bladder Cancer Company, announces the publication of the study “Clinical and Economic Impact of Blue Light Cystoscopy in the Management of NMIBC* at U.S. Ambulatory Surgical Centers: What is the Site-of-Service Disparity?” in Urologic Oncology this week. The research objective was to quantify the clinical and economic impact of the incorporation of BLC in the management of NMIBC in ambulatory surgical centers (ASCs) considering 2022 Center for Medicare Services (CMS) patient-physician coverage and reimbursement.
Background: Cxbladder diagnostic tests combine genomic information from urinary mRNA with phenotypic information to either rule out low-risk individuals or identify patients at a high risk of urothelial carcinoma (UC).

Objective: To evaluate the performance of Cxbladder and urine cytology, and Cxbladder's adjudication of atypical cytology and equivocal cystoscopy.

High-definition blue light cystoscopic imaging showcased at the European Association of Urology (EAU) Congress, Amsterdam

Reno, Nevada (UroToday.com) -- Photocure ASA, The Bladder Cancer Company, announces that its collaborations with capital equipment providers support the most advanced technologies including recent blue light system upgrades.
Reno, Nevada (UroToday.com) -- Photocure ASA (OSE: PHO), the Bladder Cancer Company, announces the commercial availability of Karl Storz’s New Blue Light equipment powered by Saphira™ in the U.S.

As part of the rollout, Karl Storz plans to host a Virtual Launch event for the medical community streamed from its El Segundo, California office where Sia Daneshmand M.D. and Kristin Scarpato M.D. M.P.H. will discuss the clinical benefits of using blue light cystoscopy (BLC®) with Cysview® for NBMIC*,

Reno, Nevada (UroToday.com) -- Photocure ASA, the Bladder Cancer Company, announces the publication of new results from its exploratory research program in the journal Biomedicines, entitled “Antitumor Effect and Induced Immune Response Following Exposure of Hexaminolevulinate (HAL) and Blue Light in an Orthotopic Model of Rat Bladder Cancer”. These results support initial pre-clinical data on the potential anti-tumor effect of HAL, which was presented at the BLADDR 2019 congress.

The therapeutic benefit of intravesical instillation of hexaminolevulinate (HAL) at the time of transurethral resection of bladder tumor (TURBT) has been demonstrated in multiple studies. The purpose of this study was to prospectively assess the safety of repeated administration of HAL from a phase III pre-trial planned analysis.

Reno, Nevada (UroToday.com) -- Photocure ASA, The Bladder Cancer Company, announces U.S. Food and Drug Administration (FDA) approval of a new and improved Blue Light system to be used with Photocure’s Cysview® product in Blue Light Cystoscopy (BLC®) procedures for the detection of non‐muscle invasive bladder cancer (NMIBC). Manufactured and soon to be commercialized by KARL STORZ Endoscopy-America, Inc. (KARL STORZ), the new Blue Light system is approved for use in procedures requiring rigid cystoscopy. FDA approval was granted to KARL STORZ on February 4, 2022.

The utility of blue light cystoscopy (BLC) in patients receiving Bacillus Calmette Guerin (BCG) during post-treatment cystoscopy is not well understood. Our objective was to determine if BLC improves recurrence detection in non-muscle invasive bladder cancer (NMIBC) patients undergoing BCG.

PURPOSE: We compared blue light flexible cystoscopy with white light flexible cystoscopy for the detection of bladder cancer during surveillance.

MATERIALS AND METHODS: Patients at high risk for recurrence received hexaminolevulinate intravesically before white light flexible cystoscopy and randomization to blue light flexible cystoscopy.

Blue light cystoscopy (BLC) during transurethral resection of bladder tumor (TURBT) is guideline-recommended as it improves cancer detection and decreases recurrence of the disease. However, the extent to which BLC is used has not been established.

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.

Photodynamic diagnosis using hexaminolevulinate (HAL)-guided BL-TURB may reduce the recurrence risk in non-muscle invasive BCa compared to standard WL-TURB due to more sensitive tumor detection. The impact of the initial use of WL- vs.

Bladder cancer remains one of the most expensive cancers to manage. Newer technologies and medications further compound costs of care. Blue light cystoscopy (BLC) has been traditionally offered in the inpatient setting, however, in-office applications are available.

To determine the estimated budget impact to practices that incorporate blue light cystoscopy (BLC) with hexaminolevulinate HCl (HAL) for the surveillance of non-muscle-invasive bladder cancer (NMIBC) in the clinic setting.

With the introduction of advanced technologies in the clinic setting such as HAL, further cost comparative research is needed to justify HAL as a high value option.

Smoking has a strong causal association with bladder cancer but the relationship with recurrence is not well established. We sought to assess the association of smoking status on recurrence of non-muscle invasive bladder cancer (NMIBC) in a contemporary cohort of patients with predominantly high-risk, recurrent NMIBC managed with photodynamic enhanced cystoscopy.

Blue light cystoscopy (BLC) with hexaminolevulinate (HAL) during transurethral resection of bladder cancer improves detection of non-muscle-invasive bladder cancer (NMIBC) and reduces recurrence rates.

Purpose: To evaluate the utility of blue light flexible cystoscopy (BLFC) for surveillance of non-muscle invasive bladder cancer (NMIBC). This was a prospective cohort of consecutive patients who underwent office BLFC for NMIBC. Clinical information was collected including cystoscopic findings and pathologic data.

Photodynamic diagnosis using the optical imaging agent hexaminolevulinate (HAL, Hexvix®, Ipsen Pharma GmbH, Ettlingen, Germany) as an adjunct to white light cystoscopy (WLC) during the initial transurethral resection of bladder tumours (TURB) improves the detection rate of bladder cancer and leads to fewer recurrences.

Blue light cystoscopy (BLC) with hexaminolevulinate (HAL) during transurethral resection of bladder cancer improves detection of non- muscle-invasive bladder cancer (NMIBC) and reduces recurrence rates. Flexible BLC was approved by the FDA in 2018 for use in the surveillance setting and was demonstrated to improve detection.

Diagnosis:

Clinical Presentation

There are no reliable screening tests available for detecting bladder cancer; hence the diagnosis is usually made based on clinical signs and symptoms. Painless hematuria – microscopic or gross – is the most common presentation and a hematuria investigation in an otherwise asymptomatic patient detects bladder neoplasm in roughly 20% of gross and 5% of microscopic cases.1,2
The American Urological Association (AUA) recommends that non-muscle invasive bladder cancer (NMIBC) patients with persistent or recurrent Ta or CIS should receive a second induction course of Bacillus Calmette-Guerin (BCG) after the first course. However, a significant number of patients decline. Real-world data evaluating the efficacy of a second BCG induction course is needed.

Nearly 80% of patients presenting with bladder cancer (BC) present with nonmuscle-invasive bladder cancer (NMIBC). Despite radical treatment, many of these patients experience disease progression. A surveillance program combining regular cystoscopy, upper urinary tract imaging, and urine cytology is typically instated to detect recurrence after radical treatment of NMIBC. This surveillance program has several shortcomings; amongst them the invasive nature of cystoscopy alongside the limited sensitivity (approximately 48%) of urine cytology.

Surveilling recurrent urothelial carcinoma (UC) requires frequent cystoscopy, which is invasive, expensive and time-consuming. An accurate urinary biomarker has the potential to reduce the number of cystoscopies required during post-treatment surveillance.

Published Date: October 2020

In 2020, approximately 81,000 cases of urothelial carcinoma of the bladder will be diagnosed in the United States, with nearly 18,000 associated deaths.1 Bladder cancer disproportionally affects men and is associated with well-defined environmental risk factors—tobacco use underlies approximately 50% of cases.2 Nonmuscle-invasive bladder cancer (NMIBC) is primarily managed by transurethral resection, risk-stratified use of intravesical chemotherapeutic or immunotherapeutic agents, and close surveillance.

Published Date: September 2018

More than 81,000 individuals are diagnosed with bladder cancer in the United States every year, of whom 75% have non-muscle invasive disease.1,2 Unfortunately, half these cases recur despite transurethral resection of bladder tumor (TURBT), and from 5% to 25% of repeated recurrences progress to muscle-invasive disease.3,4,5

Blue light cystoscopy (BLC) using hexaminolevulinate (HAL/Cysview/Hexvix) has been previously shown to improve detection of non-muscle-invasive bladder cancer (NMIBC). Herein, we evaluated the detection of malignant lesions in a heterogenous group of patients in the real world setting and documented the change in risk category due to upstaging or upgrading.

Blue-light cystoscopy (BLC) is a photodynamic diagnostic technique that augments the detection of occult disease missed under traditional white light. Instillation of hexaminolevulinate, a heme precursor, causes preferential accumulation of protoporphyrin IX and other photoactive porphyrins in neoplastic cells, which are then excited under the wavelength of blue light (~450 nm) to fluoresce red. The sensitivity of BLC in detecting cancerous lesions is much higher than that of white-light alone (91% vs. 76%) and used together, BLC plus WLC has a sensitivity of 98.5%.1 

A 90-year old man with no significant past medical history presented to urology clinic complaining of gross hematuria, urinary frequency, and dysuria. Previous urine cytology was atypical but two white-light cystoscopies failed to show any lesions.

Conference Coverage
Conference Highlights Written by Physician-Scientist
Presented by Sima Porten, MD, MPH

 The 23rd Annual Meeting of the SUO was host to a session on the real life impact of CxBladder tests for the diagnosis and surveillance of bladder cancer. Dr. Sima Porten began her presentation by noting that there has been an “explosion” of “at home” tests, many of which have been approved by the US FDA. The most prominent example of this is the Cologuard stool DNA tests for colorectal cancer screening that has seen widespread adoption in the United States.

Presented by John Sfakianos, MD

The 23rd Annual Meeting of the SUO was host to a session on the real life impact of CxBladder tests for the diagnosis and surveillance of bladder cancer. Dr. John Sfakianos began his presentation by noting that current guidelines for surveillance provide little concrete guidance for when surveillance may be stopped. The AUA currently provides the following guidance by risk category

Presented by Sia Daneshmand, MD
The 2022 Society of Urologic Oncology (SUO) annual meeting featured a session on bladder cancer, including a presentation by Dr. Sia Daneshmand discussing the impact of blue light cystoscopy on tumor recurrence in non-muscle invasive bladder cancer patients treated in a real-world setting.
Presented by Stephen B. Williams, MD, MS, FACS
Current studies are underway evaluating the use and outcomes of blue light cystoscopy in a real-world setting. This study from an equal access setting in the VA observed a significantly decreased risk of recurrence and prolonged time interval to recurrence following BLC compared to the pre-study WLC. There was no difference in any bladder cancer outcomes by race. In this presentation Stephen B. Williams BLC decreased rates of recurrence and longer time intervals to recurrence with the use of BLC.
Presented by Stephen B. Williams, MD, MS, FACS
Blue Light Cystoscopy (BLC) has become an important clinical procedure for bladder cancer management, especially as research suggests that BLC can reduce recurrence rates compared to White Light Cystoscopy (WLC).   However, there is currently a lack of real-world data evaluating the risk of bladder cancer recurrence and progression in an equal access setting, and by race, among those treated with BLC. The primary objective of this study presented at the IBCN was to assess the impact of BLC with Cysview on recurrence and progression in an equal access setting by race.
Presented by Neal D. Shore, MD & Trinity Bivalacqua, MD, PhD
The 2022 Annual Meeting of the American Urological Association was host to a case-based debate regarding the role of repeat transurethral resection of bladder tumors (TURBT) for all high grade non-muscle invasive bladder cancers (NMIBC). This session was expertly moderated by Dr. Neal Shore, and Dr. Trinity Bivalacqua was tasked with arguing in favor of repeat TURBT in this setting.
Presented by Muhannad Alsyouf, MD
The 2022 American Urological Association (AUA) Annual Meeting included a session on the epidemiology and evaluation of bladder cancer and a presentation by Dr. Muhannad Alsyouf discussing whether a restaging TURBT is necessary for high risk Non-Muscle Invasive Bladder Cancer (NMIBC) if the initial TURBT was performed using blue light.
Presented by Lars Dyrskjøt, PhD
On the second day of the American Society for Clinical Oncology (ASCO) Genitourinary Cancer Symposium 2022 focusing on urothelial carcinoma, Dr. Lars Dyrskjøt discussed the role of ctDNA (circulating tumor DNA) in patients with muscle invasive bladder cancer (MIBC) for assessment of therapy response, stratification of the risk of recurrence, and early detection of relapse, in a session focused on a Potpourri of Hot Topics in Urothelial Carcinoma.
Presented by Taketo Kawai, MD
Dr. Kawai presented an analysis assessing the role of photodynamic diagnosis-assisted TURBT (PDD-TURBT) to reduce the residual tumor in patients with high-risk non-muscle-invasive bladder cancer (NMIBC). High-risk NMIBC has a high rate of residual tumor following TURBT (40-60%). 
Presented by Michael L. Creswell
 The SUO annual winter meeting included a bladder cancer session and a presentation by Dr. Michael Creswell discussing the economic outcomes of hexaminolevulinate blue-light cystoscopy compared to white light cystoscopy for the diagnosis and monitoring of non-muscle invasive bladder cancer (NMIBC).
Presented by Sanam Seyedian, MD
The role in the surveillance of patients following intravesical therapy has not been established. In a podium presentation at the American Urologic Association Virtual Annual Meeting, Dr. Seyedian and colleagues presented the results of their analysis examining this question.
Presented by Anne K. Schuckman, MD
The optimizing personalized management of non-muscle-invasive bladder cancer session at the 2021 American Society of Clinical Oncology Genitourinary Cancers Symposium (ASCO GU) included a presentation from Dr. Anne Schuckman discussing which patients with high-risk non-muscle-invasive bladder cancer may benefit from radical cystectomy.
Presented by Max Kates, MD

There have been several recent single-arm trials in the Bacillus Calmette-Guerin (BCG) unresponsive non-muscle invasive bladder cancer (NMIBC) setting. The first question that arises is whether these single-arm trials are enough or do we need to randomize patients for our future trials.

Presented by Marc-Oliver Grimm, MD
In an oral presentation in the New Trials Update session at the 12th European Multidisciplinary Congress on Urological Cancers (EMUC), Dr. Marc-Oliver Grimm discussed the results of the NIMBUS trial, Treatment of High-Grade Non-Muscle Invasive Urothelial Carcinoma of the Bladder
Presented by Nathan Brooks, MD
Dr. Nathan Brooks, Society of Urologic Oncology (SUO) Fellow at the MD Anderson Cancer Center, Houston, Texas, USA presented “Correlation Between Body Mass Index (BMI), diabetes mellitus (DM), and Outcomes in Patients Treated with Bacillus Calmette Guerin (BCG)
Presented by J. Alfred Witjes, MD, PhD
J. Alfred Witjes, MD, PhD, began his talk explaining that he believes cystoscopy is still needed in the primary diagnosis of bladder tumors. Cystoscopy gives important information regarding multiplicity, size, stage, the grade of bladder tumors, and OR planning.
Presented by Ashley Alford, MD
Prior randomized controlled trials have demonstrated that the use of blue light cystoscopy (BLC) is associated with improved detection of both carcinoma-in-situ and papillary bladder tumors. As a result, BLC is recommended for use in patients with a history of non-muscle-invasive bladder cancer
Presented by Hamed Ahmadi, MD
Blue light cystoscopy has been shown to not only increase the detection rate of non-muscle invasive bladder cancer (20% for any tumor) including carcinoma in situ (CIS; 25-43%), it also decreases recurrence (27% at 12 months) and progression rates (24% at 24 months).
Presented by Marie Andersson, MD
The diagnostic process may be extensive in patients with non-muscle invasive bladder cancer (NMIBC) who have positive or suspicious urinary cytology when white-light flexible cystoscopy is negative. The next step in management is typically to proceed with resection biopsies
Presented by Anne Schuckman, MD
At the American Urological Association (AUA) 2020 Virtual annual meeting, Dr. Anne Schuckman discussed blue light cystoscopy for bladder cancer and several of her tips and tricks. Dr. Schuckman notes that there are over 75,000 new bladder cancer diagnoses per year, leading to more than 15,000 deaths. The prevalence of bladder cancer is >550,000 cases, making it the highest per capita treatment cost due to recurrent disease and multiple recurrences.
Presented by Wassim Kassouf, MD, FRCS
San Francisco, California (UroToday.com) Treatment of patients with Bacillus Calmette-Guérin (BCG)-unresponsive non-muscle invasive bladder cancer (NMIBC) remains a significant
Presented by Eugene Shkolyar, MD
The gold standard for evaluation and diagnosis of new bladder cancer and for surveillance of patients with non-muscle invasive bladder cancer (NMIBC) remains cystoscopy. However, as has been clearly demonstrated before, cystoscopy is not a perfect test – besides being user dependent, white light cystoscopy
Presented by Gorm von Gohren Edwin
More than 81,000 individuals are diagnosed with bladder cancer in the United States every year, of whom 75% have non-muscle invasive disease. Unfortunately, half these cases recur despite transurethral resection of bladder tumor (TURBT), and from 5% to 25% of repeated recurrences progress
Presented by Yair Lotan, MD
Yair Lotan, MD discussed the use of blue light cystoscopy with CYSVIEW® in patients with non-muscle invasive bladder cancer (NMIBC). Dr. Lotan notes that there are several unmet medical needs with regards to NMIBC. First, it is associated with a high risk of recurrence, with up to 61% of patients recurring in the first year, and up to 78% within 5 years. Second, NMIBC may progress to muscle invasion
Presented by Ricardo Leão, MD
Barcelona, Spain (UroToday.com) Up to 3/4 of non-muscle invasive bladder cancer (NMIBC) patients will endure recurrence during their lifetime. Disease follow up is invasive, costly and long and consists of cystoscopy, cytology, and imaging. The most prevalent non-invasive approach for the diagnosis of recurrence remains urinary cytology,
Presented by Yair Lotan, MD
Barcelona, Spain (UroToday.com) At the urogenital cancer treatment session, Dr. Yair Lotan discussed the impact of blue light flexible cystoscopy and utilization in the clinic setting. Dr. Lotan notes that there are several unmet medical needs with regards to non-muscle invasive bladder cancer (NMIBC). First, it is associated with a high risk of recurrence, with up to 61% of patients recurring in the first year, and up to 78% within 5 years.
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