Reduction in the Risk of Recurrence with the Use of Blue Light Cystoscopy Use Among Patients with Non-Muscle Invasive Bladder Cancer In An Equal Access Setting - Stephen Williams

February 27, 2023

Sam Chang is joined by Stephen Williams to discuss the impact of Blue Light Cystoscopy (BLC) use among patients with non-muscle invasive bladder cancer (NMIBC) in an equal access setting, specifically the Veterans Affairs (VA) system. Prior studies suggest that white light cystoscopy (WLC) alone can fail to detect cases of NMIBC compared to BLC. Dr. Williams explains that they found a roughly 30% decrease in risk of recurrence in patients that underwent blue light versus white light and a prolonged period of recurrence for those patients that underwent blue light versus white light. Important to note in this population, roughly 70% were deemed high-risk, non-muscle invasive bladder cancer patients. Dr. Williams concludes the discussion by looking at the future of BLC and NMIBC studies.


Stephen B. Williams, MD, MS, FACS, Chief, Division of Urology, Director of Urologic Oncology, Urologic Research, Medical Director for High-Value Care, University of Texas Medical Branch, Galveston, Texas

Sam S. Chang, M.D., M.B.A. Patricia and Rodes Hart Endowed Chair of Urologic Surgery Professor Department of Urology at Vanderbilt University Medical Center

Read the Full Video Transcript

Sam Chang: Hello, my name is Sam Chang. I'm a urologist in Nashville, Tennessee. And I have the great honor and pleasure of... Whenever I get to interact with colleagues, it's always a great pleasure. I'm here with Dr. Stephen Williams. Stephen is actually now the Chief Medical Officer at UTMB and the chief of urology there in Texas. And we're quite lucky to have him. He's going to speak a little bit on the abstract that was presented at GU ASCO 2023. Looking at the impact, I think favorable impact, of Cysview on patients in an equal access system. So Stephen, first of all, thanks for being here and spending some time with us, but give us a little overview of the abstract that was presented.

Stephen Williams: Well, thank you so much and UroToday for having me. And I know it comes out as a, it's a timely topic regard for Cysview and really an equal access setting. First off, I do not work inside of a VA, but I do have an appointment to study research in that setting. And I think one thing from my prior population based research, I always wanted to investigate or try to attempt to control for access to care. And the VA or Veterans Affairs health system is the largest equal access setting, at least in the United States. So one of the questions that I've had always is in that setting, what is the difference, if any, in outcomes in patients that undergo blue light versus white light? And in doing so, we're able to perform a large retrospective study, roughly large, although the numbers always begged in question, but there's a lot of granularity in the patients. There's about 378 patients that we studied from 2014 to 2020 that had at least one year of follow up in patients that underwent blue light cystoscopy.

And this is just one step of many that were anticipating in doing in regard for really assessing whether or not there are a difference in any of the outcomes. And the primary outcome that we're trying to assess is recurrence in patients comparing blue light cystoscopy, but then also for those patients that underwent white light.

And in doing so, we found actually a decrease, roughly 30% decrease risk of recurrence in patients that underwent blue light versus white light. But actually what was more pivotal at all the time points up to five years even, we found a prolonged time period of recurrence for those patients that underwent blue light versus white light. So not only decreased risk of recurrence, but there's a delay to that recurrence. Important as well in this population, roughly 70% were deemed high risk, non-muscle invasive bladder cancer patients. In addition, roughly 70% had exposure to BCG, but we didn't look and assess. And something that we did do in another study is greater than 70 or 90% actually received induction, adequate induction BCG, and then 30% received adequate maintenance. But once again, we didn't look at that kind of granularity, but really highlights actually the patients perhaps that may derive most benefit in blue light are those that are high risk-

Sam Chang: Are there higher risk patients that are the ones that are most likely to occur, number one, but also have a higher chance of progression. And so by decreasing that chance of recurrence, you can see the benefit of not only avoiding procedures, but hopefully possibly even avoiding progression. So when looking at that comparison of the blue light and white light, you can see the differences in curves. And obviously there's been recent literature looking at the impact at a different kind of time point. So give me an idea. I know we're comparing apples to oranges, but give me an idea of a comparison of that versus the recent study looking at perhaps the impact of blue light not being as favorable.

Stephen Williams: Sure. PHOTO is the trial that just came out, and that's important, Sam, that those patients in that study were deemed more low grade or low risk. And then in addition, had inadequate, I think therapy given that limited number of patients had BCG. Now I think what is critical, and you pointed out, in this study granted that it's not a randomized trial, it doesn't have that gold standard or gold stamp, really provides hypothesis generating information to analyze and assess whether or not in those that are the highest of high risk, which we're really concerned with, progression. We didn't notice any difference in any of the outcomes, also too, in our study, according to race by race. So in an equal access setting, I think that's pivotal, particularly given African-Americans have a worse survival, more advanced stage when they present, and really worse outcomes when we're looking at assessing those patients in non-equal access settings.

Sam Chang: Yeah, I think that's really important. Were there enough female patients to see differences in gender?

Stephen Williams: So yeah, as you know, within the veter- VA system, it was predominant male cohort.

Sam Chang: Yes.

Stephen Williams: But with that being said too, though males in a four to one fashion have an increased risk of bladder cancer. I think these findings are provocative. And we did include though male and female to be honest, but it was roughly about 97% male. So it essentially is a male study.

Sam Chang: And I think to me, just as exciting as you gather this data, I know you're also obviously looking at different types of therapies, the impact of repeat TURs, et cetera. So I look forward to many, many more studies coming from these group of individual studies that you've looked at. But from what it seems like you've also brought in other authors, other institutions in this research as well. Is that true?

Stephen Williams: Absolutely. We have to tap into the wealth of intellectual capital. I'm a collaborative by nature, and I know this is definitely not my study, but our team's effort looking at also costs, equal access, but really involving individuals from Durham, Cedar Sinai, MD Anderson. In addition, fellows from numerous places, one of which is going to be your faculty soon. And they actually... I learned a tremendous amount from all of those individuals. And that really leads to, I think, pivotal findings and often the next step of future research as you alluded to.

Sam Chang: So in looking at future blue light studies or non-muscle invasive bladder cancer studies, where are you guys looking next?

Stephen Williams: So right now we're actually going to dig in a little bit deeper. I can't elicit everything at this point, but much as what you-

Sam Chang: Lift your seal here. This is a-

Stephen Williams: We're in the nest.

Sam Chang: ... just an intimate environment, hopefully 1000s of people looking at this podcast and video, et cetera. But where else though, seriously, is exciting for you guys?

Stephen Williams: Sure. No, I think we're just going to dig deeper into the treatments that are being rendered and then really look and compare in a match cohort, patients that are blue light versus white light alone. And then like I alluded to also too is with BCG, the granularity and then healthcare resource cost utilization. We've done some work before in a high risk non-muscle invasive bladder cancer, but we never looked really into the blue light and whether or not that does provide some real world evidence to support its continued use. And I believe really it does have a role. Not one size fits all by any means. But that's where we have to take all this information and really provide... I think this is a value added asset to institutions and our patients.

Sam Chang: Great points. Stephen, thank you as always for spending some time with us and with our audience at UroToday. And appreciate all your collaborative efforts and the research initiatives that you've helped kind of spearhead are really moving the field forward. So thanks to you and to all your collaborators.

Stephen Williams: Thank you very much.