Management of nonmuscle-invasive bladder cancer
The management of NMIBC has been well-established,16 with the central tenets being: a complete initial resection of cancer, close surveillance for progression and recurrence with cystoscopy, and use of intravesical immunotherapy or chemotherapy with a maintenance regimen. However, multiple studies have shown extremely low rates of compliance with level I evidence and national guidelines.
For example, a meta-analysis of seven randomized trials found that instillation of chemotherapy after transurethral resection of a bladder tumor (TURBT) was associated with about a 40% risk reduction in bladder cancer recurrence.22 However, several studies in the SEER–Medicare database have found that instillation of chemotherapy immediately after TURBT occurs extremely rarely.23 In addition, 40% of providers did not perform at least one cystoscopy, cytology, or course of immunotherapy for their patients within 2 years of initial diagnosis. Surgeon compliance with guidelines accounted for almost half of the variation in compliance with post-TURBT intravesical chemotherapy.24 Likewise, despite level I evidence that bacillus Calmette-Guérin (BCG) instillations with a maintenance protocol can significantly lower the risk of recurrence and progression,25 less than half of patients with NMIBC received a single dose of induction or maintenance BCG.26
The completeness of the initial TURBT resection also shows significant variation in its quality. In one study of a high-volume tertiary care center, 74% of patients referred from an outside urologist found residual tumor in the patients who underwent a second TURBT, 30% of whom were upstaged to muscle invasion.27 This can have important implications, as delays beyond 3 months between diagnosis of muscle invasion and definitive treatment can significantly affect survival.28 Improving compliance with level I evidence and national guidelines can improve bladder cancer outcomes while decreasing the costs associated with disease progression or recurrence.
Blue-light, or fluorescence, cystoscopy (BLC) was developed to enhance a complete resection during TURBT and improve cancer detection. Several studies have found significant reduction in recurrence of about 40% with BLC compared to standard white-light cystoscopy.29 The use of BLC can significantly decrease the overall costs of NMIBC treatment,29-33 primarily powered from a 20%-60% decrease in the number of TURBTs. The total costs of a TURBT at an academic medical center can range from $3,000 to $6,000,34 so the utilization of BLC to improve complete resections has the potential to improve cancer outcomes and decrease costs.
However, significant up-front expenditures have to be considered in the utilization of photodynamic visualization, including Foley catheters for instillation, increased surveillance for patients that are up-staged with BLC, and any new equipment costs for BLC compatibility. Many of the current studies differ in their cost assumptions and follow-up, so future research will be required to help clarify the true cost-effectiveness.