IBCN 2022: The Impact of Blue Light Cystoscopy Use Among Non-Muscle Invasive Bladder Cancer Patients in an Equal Access Setting: Implications on Recurrence and Time to Recurrence by Race

(UroToday.com) Bladder Cancer is the 6th most common type of cancer in the United States and is estimated that there will be 81,180 new cases with approximately 17,100 dying of this disease in 2022.¹  Of newly diagnosed bladder cancer cases, approximately 75% are non-muscle-invasive bladder cancer (NMIBC).¹  Racial disparity have been previously described with Blacks noted to have worse bladder cancer-specific survival and are associated with up to a 2-fold increase of bladder cancer-specific death when compared to Whites.^2-6  Against this backdrop, and as new technologies emerge to diagnose and treat bladder cancer, it is critical to understand implementation taking into account disparities in treatments and outcomes.

Since its introduction in 2004, 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).^7-9  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. Some evidence suggests that WLC can fail to detect cases of non-muscle invasive bladder cancer (NMIBC) as compared to BLC, with those tumors that remain unidentified potentially able to progress to a higher stage and lead to more aggressive interventions, including chemotherapy and need for cystectomy.^10,11  Thus, less effective surveillance using WLC alone may result in missed diagnoses and thus progressive disease, ultimately leading to inferior oncologic outcomes. 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.

A total of 378 NMIBC patients within the Veterans Affairs system that underwent BLC with previous history of WLC from January 1, 2018 to December 31, 2020 were assessed. They determined recurrence rates and time to recurrence prior to BLC (i.e. after previous WLC) and following the BLC. They used the Kaplan-Meier method to estimate event-free survival and Cox regression to determine the association between race and recurrence, progression, and overall survival.

Of 378 patients with complete data; 43 (11%) were Black and 300 (79%) White. Median follow-up was 40.7 months. There were 194 (51%) patients with either T1 HG or T1 without CIS; 52 (14%) had CIS with or without TaHG or T1; and 127 (34%) had TaLG only. A total of 239 (63%) patients received BCG. Median time to first recurrence following BLC was longer compared prior to WLC (40 (33-NE) vs. 26 (17-39) months). The risk of recurrence was significantly lower following BLC (Hazard Ratio (HR) 0.70; 95% Confidence Interval (CI) 0.54-0.90). There was no significant difference in recurrence (Hazard Ratio (HR) 0.83; 95% Confidence Interval (CI) 0.48-1.43), progression (HR 1.46; 95% CI 0.45-4.74), and overall survival (HR 0.69; 95% CI 0.29-1.65) following BLC by Black vs. White race.

In conclusion, this study from an equal access setting in the VA, they observed 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.

It has been well established that accessibility of healthcare services is an important driver of bladder cancer outcomes. Cole et al. found that differences in survival for black and white bladder cancer patients was due to disparities in access and treatment.¹²  In an equal-access setting, our study found that patients were at lower risk of developing recurrence in their bladder cancer following BLC than following WLC alone. Previous studies have shown better quality of cancer care in the VA comparted to the private sector.¹³  As well, further research found no differences in complications or readmissions by race or SES among patients in equal-access settings.^14,15  Taken together, these findings suggest that equal-access systems may improve access to cancer care thereby possibly negating differences in outcomes by other social determinants in population-level data.¹³ 

This study presented at the IBCN has several notable findings. First, they describe BLC use in the largest equal access healthcare system in the US for the first time: the VA. Since its FDA approval in 2010, BLC is increasingly utilized clinically as it improves the detection rate of NMIBC by up to 43%.^16,17  This is especially important because WLC alone can fail to detect up to 20% of bladder cancer lesions.¹⁸  However, there has been conflicting evidence of whether BLC also improves recurrence and progression.^7-9,19  Within an equal-access setting, this study found that the risk of bladder cancer recurrence was significantly lower in patients following BLC than WLC alone. However, there was no significant difference in recurrence-free rate, progression, or survival in patients following BLC. This finding is important because it provides evidence that BLC is not superior than WLC in lowering progression or improving overall survival. Though decreased recurrence may lead to fewer follow-up treatments (e.g. TURBT), the question then becomes whether the cost of fewer but more expensive BLC is less than more frequent but less expensive WLC. Several studies report promising cost-savings with BLC, though with a few caveats. In a cost-consequence analysis of BLC, researchers found that BLC would be more cost-effective than WLC if BLC eventually improves progression rates.²⁰  As well, in a U.S. study of new NMIBC cases, Garfield et al. estimated a cost saving using BLC of $4660 per patient over five years compared to patients initially receiving WLC; though, the generalizability may be limited as the probabilities used were primarily from the best-case scenario from prior analyses. ²¹  Though there is a potential of cost-savings with BLC, such a savings would not be achieved solely through decreased resource utilization due to reduced recurrence.

Second, they found decreased recurrence and longer time to recurrence following BLC. Previous research comparing WLC vs. BLC recurrence has been controversial.²²  A recent Cochrane review by Maisch et al. found that BLC may reduce the risk of disease recurrence compared to white light by 34% in their aggregate analysis of 2,994 patients across 15 RCTs (HR, 0.66; 95% CI, 0.54-0.81).²²  Our findings suggest in an equal access setting, BLC may not only decrease rates of recurrence but have a longer time interval to recurrence. This may have a substantial downstream impact on further diagnostic and therapeutic options for these patients aside from improved outcomes.

Third, they described BLC use and outcomes by race in an equal access setting. Racial disparities in bladder cancer care have been previously described which have been largely attributed to socioeconomic status and access to care.^12,23  Blacks continually have worse bladder-cancer specific survival than all other racial/ethnic groups.²³  However, there remains a lack of data examining BLC outcomes by race. Given that BLC has shown to reduce progression, recurrence, and improve overall survival, they aimed to study a more homogenous population of patients with NMIBC and describe their outcomes following BLC according to race. ²⁴  Within the largest equal-access health care system in the United States, they found no significant difference in recurrence, progression, or survival following BLC between Black and White patients with NMIBC. Though there is robust research that show that Black patients have higher grade disease and worse disease-specific survival, there is a lack of data examining outcomes after BLC by race.^25,26  They found no significant difference in recurrence, progression, or survival following BLC by race. Barocas et al. analyzed the National Cancer Database and found that appropriate treatments and improved access to care reduced the risk of mortality in bladder cancer patients by 75%, and that poorer access (income, insurance type, education, and distance from care center) most contributed to the excess risk of death.¹²  As reported by these authors and in our real-world study, access to care is a critical factor to mitigate racial disparities in cancer care.

The findings of the study presented at the IBCN must be interpreted within the context of the study design. First, this was a retrospective study within an equal-access health care system and the results may not be generalizable. Second, the data was both programmatically abstracted and hand- abstracted from chart reviews for several VA locations. Thus, they were unable to adjust for all potential known and unknown confounding variables and were unable to capture all the follow-up received from outside the VA system. At the same time, though, the hand re-viewing of charts may have improved the accuracy and comprehensiveness of our data compared to prior claims- only studies. Fourth, albeit larger than observed in other bladder cancer series, our cohort was limited in the number of Black patients, which limited our power for detecting modest associations.^18,22,27  Nonetheless, the results suggest that outcomes following BLC in NMIBC patients did not differ significantly by race in an equal- access setting, although future larger comparative studies are needed to confirm our findings. Finally, race was self- reported in the current study. Given that race is a social construct and that our study was retrospective in nature, they thought that self- reporting was ideal for comparisons by race. This is important because race is often used as a proxy for social factors; and as our study utilized a homogenous cohort with respect to equal access to care, our findings are timely given increased focus on access to care as we cross the quality chasm. ^28,29 

Presented by: Stephen B. Williams, MD, MS, FACS, Division of Urology, University of Texas Medical Branch, Galveston, TX; Department of Surgery, University of Texas Medical Branch, Galveston, TX

Written by: Stephen B. Williams, MD, MS, FACS, Division of Urology, University of Texas Medical Branch, Galveston, TX; Department of Surgery, University of Texas Medical Branch, Galveston, TX during the International Bladder Cancer Network Annual Meeting, September 28-October 1, 2022, Barcelona, Spain

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