Value Based Care in Surveillance of Non-Muscle Invasive Bladder Cancer – Stephen Williams

September 22, 2021

Stephen Williams joins Ashish Kamat presenting findings on macro and microeconomics of blue light cystoscopy (BLC) with CYSVIEW® in the care of patients with non-muscle invasive bladder cancer, a Urologic Oncology Seminars and Original Investigations publication. The aim of the study was to determine the estimated budget impact to practices that incorporate blue light cystoscopy with hexaminolevulinate HCl (HAL) for the surveillance of non-muscle-invasive bladder cancer (NMIBC) in the clinic setting. Drs. Kamat and Williams highlight a few topics in a short discussion including the cost-benefit to my practice and my patient if I use blue light, the differential costs in different settings, as well as things we have learned through our use of BLC in the United States that may help other countries starting to use blue light cystoscopy more.


Stephen B. Williams, MD, MS, FACS, Chief, Division of Urology, Professor of Urology and Radiology (Tenured), Robert Earl Cone Professorship, Director of Urologic Oncology, Director of Urologic Research, Co-Director Department of Surgery Clinical Outcomes Research Program, Medical Director for High-Value Care, UTMB Health System, Galveston, Texas

Ashish Kamat, MD, MBBS, Professor, Department of Urology, Division of Surgery, University of Texas MD Anderson Cancer Center, President, International Bladder Cancer Group (IBCG), Houston, Texas

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Ashish Kamat: Hello, and welcome to UroToday's Bladder Cancer Center of Excellence. I'm Ashish Kamat, Professor of Urologic Oncology and Cancer Research at MD Anderson Cancer Center in Houston. And it's a great pleasure to welcome today a friend and a colleague from right down the street, so to speak, from Galveston, Dr. Stephen Williams, who is Medical Director for High Value Care, Professor, Chief of Division of Urology, and holds multiple other titles at the UT MB Galveston Department of Urology.

Dr. Williams clearly needs no introduction. He has done a lot of work when it comes to economics in bladder cancer and multiple different fields and arenas, is well-recognized for his work, for example, in comparing and contrasting radiation therapy with radical surgery. And that's why it was very exciting when he approached our group and invited us to collaborate on this effort on macro and microeconomics of blue light cystoscopy with CYSVIEW in the care of patients with non-muscle invasive bladder cancer, which was recently published in Urologic Oncology seminars and original investigations. Stephen, we are all excited to have you present to us your findings and have a short discussion at the end and looking forward to it. So with that, I'll hand the stage over to you.

Stephen Williams: All right. Well, thank you so much, Ashish, for that kind introduction. As you and I both know, we've worked a long time together, and I must credit a large body of this work listening to you and pushing me to look into areas that previously had not been explored. So today I'll be discussing macro and microeconomics of blue light cystoscopy in non-muscle invasive bladder cancer.

So the cost of bladder cancer care, as many of you may already know, cancer care is quite substantial within the United States. And the estimated cost of bladder cancer will increase from 4 billion to 6 billion in 2020. And bladder cancer is one of the most costly cancers, and costs increase with more advanced disease. However, there's limited studies that addressed the economic considerations in bladder cancer despite the large financial impact of managing this disease.

So value-based care is a common term that we tend to use these days and basically is identify outcomes or improving outcomes at decreased costs. But what's pivotal is actually the appropriate allocation of treatments to improve the quality of life for our patients.

The background and methods, particularly for this study, we wanted to determine using an estimated budget model that incorporates white light cystoscopy with CYSVIEW for the surveillance of non-muscle invasive bladder cancer in the clinic setting. Projected costs were at two years for a simulated facility with 50 newly diagnosed bladder cancer patients. Treatment and surveillance cystoscopy intervals were based on clinical guidelines provided by the AUA. And clinical inputs, including stage, grade, at diagnosis, rates of recurrence and relative risk reduction when using blue light as well as white light cystoscopy were derived from prior published studies. And cost inputs were based on Medicare reimbursement rates and facility costs.

This diagram here illustrates our flow model, which is quite complex. But if you focus on the tab B, we wanted to identify known or suspected bladder cancer patients as well tumor detected. But also particularly in non-muscle invasive bladder cancer, we know low, intermediate and high risk in non-muscle invasive bladder cancer being a heterogeneous disease, really try to identify the costs that are associated, particularly with recurrence and progression, if and when we use and incorporate blue light cystoscopy.

In our results, we identified use of blue light cystoscopy identified nine additional recurrences over two years compared to white light. In addition, use of flexible blue light for surveillance marginally increased cost to the practice with a net difference of 76 cents per cystoscopy over two years.

This study is not without limitations and as any observational study is performed, this also has assumptions and assumes the risk of recurrence based on prior data. Heterogeneous practice patterns, including workflow were not accounted for, and these are Medicare costs and cannot comment on other third-party payers. And this is not a cost effectiveness study as this would need analysis of quality of life years gained. And in addition costs are up to two years from diagnosis date.

But our conclusion is based upon that flexible blue light cystoscopy surveillance of non-muscle invasive bladder cancer may result in a modest increase in costs per cystoscopy. However, this must be balanced against flexible blue light resulting in identification of nine additional recurrences over two years that otherwise would be missed by white light alone, resulting in more effective TURBTs and potentially lower risk of progression. This study was published in Urologic Oncology, and I'd like to thank everyone's efforts, including Drs. Kamat and Siamak Daneshmand for their expertise and guidance.

And as a closing slide, I like this. This is based on our SpaceX. I think Tomorrowland is no more. Oncologic outcomes in the context of cost and value-based pricing is here. And I'd like to thank everyone for allowing me to present this information.

Ashish Kamat: Thank you so much, Stephen. That was a nice succinct summary of your findings. If you could chat a little bit, one of the questions that folks often ask, and this is a very practical question and maybe not specifically related to your publication, but I'll ask anyways is, what's the cost benefit to my practice and my patient if I use blue light? And can you sort of put that in layman's terms for our audience?

Stephen Williams: Sure. So from our study, the costs benefit and an example, actually, I like to use because this is real world is using this information to inform my institution, to incorporate flexible blue light cystoscopy in our clinical setting. So using this model and this information, there are upfront costs, which in layman's term is the sticker price shock. And looking at the downstream benefit of the additional improved value to the patient is critical, but we identified about 76 cents being a difference. However, important is also what costs you're mitigating in a study that we have done and I know you have done as well separately looking in the high-risk non-muscle invasive bladder cancer, what we could do to hopefully help mitigate further progression and the downstream costs that we can avoid in already an expensive cancer that, that is really innovative and transformative cost-effective and cost conscious, if I could say, decision-making as a healthcare system.

Ashish Kamat: Thanks for that. And what about the differential costs in different settings, any pearls and tips along those lines?

Stephen Williams: Yes, I think one thing when we published the manuscript was that in fact there's different scenarios and workflows, and based upon those is actually having a designated team as well as an understanding on trying to optimize not only the workflow for incorporating blue light, but then the additional patients that we all tend to see so that we don't hinder progress or more importantly care of other patients.

Ashish Kamat: And a very important point because clearly, sometimes we'll hear folks say, "Well, I would like to use blue light, but it's going to hinder the workflow. And I can't take care of any other patients at all during the day." And that may be true the first or second time you use blue light in the office, but if your workflows streamline, that really shouldn't be the case, right? And that's something that's a very practical point that you make.

So moving attention a little bit to other countries, for example, in Japan, they've just recently in the last two or three years had the agent for blue light cystoscopy approved and are starting to use it more and more. Are there errors and mistakes that we made here in the US from your study that you could point to other countries and say, "Hey, don't make the same mistakes."?

Stephen Williams: Well, I wish I had that magic ball, if you will, to foresee the future, but trying to understand of course circumstances that we made here. I think in regard for incorporating blue light and flexible blue light, I think we've done a fairly good job on the appropriateness. You've helped lead this initiative, Ashish, as well as colleagues from around the country to really make certain that when we're using blue light, there are in the appropriate patient. It's not a one size fits all approach, but particularly in those patients that you're concerned for perhaps under staging or have a heightened risk for recurrence or progression, i.e., Those high risk, non-muscle invasive bladder cancer patients after receiving BCG. I tend to incorporate those, but I think also it's important to appropriately allocate those resources in times when there are consideration beyond oncologic, but the costs of course associated with this. But having a dedicated team that I've learned from you and at MD Anderson, and now I've applied to my institution, I think really also helps the implementation and dissemination of blue light.

Ashish Kamat: Yeah. Again, you hit all the right points. Let me get back to your paper for a second, because obviously with the analysis that you performed and showed that there's a net difference of less than a dollar per cystoscopy over two years. Clearly, this is based on Medicare costs, and you did allude to the fact that we can't really talk about third party payers. But do you foresee that this difference in cost would be dramatically different amongst other payers? I mean, can you hypothesize along those lines?

Stephen Williams: Yes, no. I think commercial payer, if you're looking in generally speaking, tend to reimburse more favorably as compared to other either government or Medicare-based payments. So I would suspect that one perhaps could extrapolate, and this is all hypothesis generating information based on prior studies, that this difference would not be even as dramatic. And it's not dramatic at this point, right? It's 76 cents per cystoscopy based upon the model that we have at present. But I don't believe this would be even a consideration when you're considering third party payers. But with this disease, of course, more commonly occurs in patients greater than 70, Medicare, at least in this country obviously, is the main insurance provider for that population.

Ashish Kamat: And clearly, a minuscule increase in cost, a dollar, even $2 per cystoscopy for the trade-off of missing tumors that you might miss that could be high grade and actually affect the outcome of our patients and actually cut short the life expectancy. Again, in your mind, in my mind, it's a no-brainer, right? But we do have to kind of have publications such as this to inform the public and the community that this is a very worthwhile endeavor and that the cost hit, so to speak, is not significant if it's done right. Stephen, just to wrap it up in the interest of time, let me give the stage back to you and maybe to have you take the next 30, 60 seconds to leave our audience with some high level thoughts and conclusions from your study.

Stephen Williams: Certainly. So I think first I'd like to thank everyone for taking the time to listen. Not only are we often concerned with the oncologic efficacy or effectiveness of our treatments, but now in a health care cost conscientious environment and given the substantial costs associated with bladder cancer care, my hope is that this work and the work that we're doing from also the treatments, but then understanding the cost will improve not only our oncologic outcomes, but reduce the financial toxicity that can be quite substantial for cancer patients and particularly bladder cancer patients.

Ashish Kamat: Thank you once again, Stephen. Stay safe. Stay well. Hopefully we'll get to see each other soon.

Stephen Williams: Absolutely. Take care, everyone.