Fluorescent cystoscopy outperforms white light method

Researchers reviewing trials looking at the effectiveness of fluorescent compared to white light cystoscopy for bladder cancer outcomes report fluorescent cystoscopy is superior to standard white light cystoscopy for reducing risk of bladder cancer recurrence.

“Fluorescent cystoscopy was also superior to white light cystoscopy for reducing risk of progression in studies that used [hexaminolevulinic acid] HAL as the photosensitizer,” said lead author Roger Chou, MD, of Oregon Health and Science University and Pacific Northwest Evidence-based Practice Center, Portland. “There were no effects on mortality, but data were limited.”

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Dr. Chou and colleagues reported that compared to white light cystoscopy, fluorescent cystoscopy was linked to a 41% decreased risk of bladder cancer recurrence at less than 3 months; a 30% lower risk of recurrence at 3 months to less than a year; and a 19% reduced risk at the long-term follow-up of a year or more.

But the findings from the systematic review and meta-analysis, published in the Journal of Urology (2017; 197:548-58), were inconsistent. The paper, reflecting findings of 14 randomized trials, suggests more research is needed to confirm these findings. One issue with the studies, according to Dr. Chou, is that most were not effectively blinded to the cystoscopic methods, which could have resulted in performance bias. There also was evidence of publication bias, as there were some negative trials that weren’t published, he said.

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“One finding that was surprising and intriguing is that the results seemed to be worse in studies in which cystoscopists knew whether patients were undergoing fluorescent cystoscopy or standard cystoscopy [versus] those that used techniques to guard against performance bias, [such as,] randomizing people to the photosensitizer instillation versus a placebo instillation and having all patients undergo fluorescent cystoscopy and standard cystoscopy. I do think that it is important that future trials should be designed to guard against performance bias,” he said. “In addition… we need more studies that evaluate long-term outcomes on progression and mortality.”

Dr. Chou, who is an internist and doesn’t perform cystoscopy, said he doesn’t believe there is a general consensus among urologists about whether to use florescent or white light cystoscopy for bladder cancer patients.

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“It’s pretty clear that fluorescent cystoscopy can identify additional lesions. But the clinical significance of this, in terms of long-term clinical outcomes-progression and mortality-are less certain… and that is what is most important for patients,” he said. “There are additional costs associated with the equipment [needed for fluorescent cystoscopy], and my understanding is that it is still not necessarily routinely available even in well-regarded referral centers.”

The review provides some support for using fluorescent cystoscopy and investing in the technologies in places that may have been on the fence or inclined to do so. It may not be enough to convince skeptics, according to Dr. Chou.

Dr. Chou has received funding from the Agency for Healthcare Research and Quality and the AUA on bladder cancer topics.

More on Bladder Cancer:

A new standard of care in muscle-invasive bladder Ca?

Novel bladder Ca agent shows promise in phase II trial

Rheumatologic side effects possible with immunotherapies

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