BLC scores well against WLC in recurrent bladder tumors

Tracy M. Downs, MD

San Diego-Fluorescent blue light cystoscopy (BLC) improves 3-year recurrence-free survival (RFS) rates in patients with recurrent bladder tumors compared to white light cystoscopy (WLC), and researchers believe its use should be expanded.

"Although BLC has been approved for index transurethral resection, its use can be extended for recurrent tumors as well," said lead author Tracy M. Downs, MD, of the University of Wisconsin School of Medicine and Public Health, Madison, in an interview with Urology Times.

According to Dr. Downs, "Transurethral resection of bladder tumor (TURBT) is the standard of care for the non-muscle invasive subtype. Yet there is concern over the ability of TURBT done with WLC to identify small papillary tumors and flat carcinoma in situ lesions. The recurrence rate at 5 years after TURBT tumor with WLC is reported to be as high as 70%."

Related: Role of blue light cystoscopy to detect bladder cancer

By contrast, "Using BLC increases detection rates of small papillary tumors by 10%-15% and carcinoma in situ lesions by 40% in meta-analyses," Dr. Downs said. "This improved cancer detection translates into improved recurrence-free survival rates. However, the effect of BLC for recurrent bladder cancer has not been well defined."

There has been previous research in this area. At the 2017 AUA annual meeting in Boston, Siamak Daneshmand, MD, presented findings from a prospective phase III clinical trial that found blue light flexible cystoscopy with intravesical hexaminolevulinate HCL (HAL [Cysview]), significantly improved the detection of recurrent bladder tumors compared with WLC.

Next: What the authors found

For the new study, which was presented at the American College of Surgeons clinical congress in San Diego, Dr. Downs and colleagues identified 159 cases of recurrent non-muscle invasive bladder cancer treated with TUR by a single surgeon; 44 cases were treated with BLC with HAL and 115 were treated with WLC. Median patient age was 74 years.

The authors found that recurrence appeared at a median of 10.6 months (interquartile range, 4.53-22.7 months). They also discovered an association between improved RFS and BLC using Cysview (an optimal imaging agent), age, multi-focality, bacillus Calmette-Guérin therapy, tumor stage, and tumor grade.

Patients were less likely to encounter tumor recurrence if they underwent BLC with Cysview (HR=0.42, 95% CI, 0.25-0.70, p=.001). Over three years, 53.7% of the BLC patients survived without recurrence compared to just 27.4% of the WLC patients (p=.004).

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"This population was at high risk of recurrence, as you can see from the recurrence rates in the WLC group," Dr. Downs said. "BLC has been shown to significantly improve recurrence-free survival in this high-risk population."

Moving forward, "The effect of BLC on preventing disease progression of bladder cancer is yet to be proven in prospective studies. The duration of prior studies was not adequate to detect a difference in the progression rates between WLC and BLC," he said. "Another concern is regarding the safety of multiple instillations of HAL for repeated use of BLC. In Europe, the European Medicines Agency approval allows for unlimited instillations. The safety of repeat use of BLC is currently being investigated."

Dr. Downs discloses serving as an expert at a symposium for Photocure.

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