BackTable Urology
Ep. 186 Blue Light Cystoscopy: Improving Bladder Cancer Detection with Dr. Suzanne Merrill
Tue, 27 Aug 2024
What is the role of blue light cystoscopy in bladder cancer? In this episode, Dr. Suzette Sutherland interviews Dr. Suzanne Merrill from Colorado Urology about the benefits of this technology in the diagnosis and treatment of bladder cancer, and how to implement it into your practice. --- CHECK OUT OUR SPONSOR Photocure https://www.photocure.com/ --- SYNPOSIS The doctors start by discussing the advantages of using blue light cystoscopy, including better detection rates of Ta and T1 lesions and the reduction of cancer recurrence by as much as 11%. They highlight the importance of complete transurethral resection of bladder tumor (TURBT) and patient compliance. Dr. Merrill emphasizes the necessity of accurate risk stratification and the logistics of real-life incorporation. Finally, she also comments on new bladder cancer technologies, such as narrow band imaging. --- TIMESTAMPS 00:00 - Introduction 03:45 - Epidemiology and Risk of Bladder Cancer 05:48 - AUA Guidelines for Bladder Cancer 08:01 - Mechanism and Benefits of Blue Light Cystoscopy 10:33 - Practical Applications 34:48 - Conclusion --- RESOURCES Photocure https://www.photocure.com/
This week on the Backtable podcast.
The data really over time has shown us that blue light is a technology that should be offered to our patients, that it has good enough evidence behind it, that it can impact our patients course of disease and outcome.
Even back in 2013, there was a meta-analysis of nine studies, which ultimately showed that detection of TA and T1 lesions may be up to 25% greater, okay, with blue light cystoscopy and use of CISFU. than compared to white light.
And overall, this translated looking at really the raw data from this meta-analysis that the rate of recurrence with use of blue light can be reduced by about 11%, and it can certainly prolong the time to recurrence by about seven-ish months.
Welcome to the Backtable podcast, your source for all things urology. You can find all previous episodes of our podcasts on Apple Podcasts, Spotify, and at backtable.com. We all know that TURBT procedure is critical in the care of patients with non-muscle invasive bladder cancer.
Unfortunately, there's data that shows that carcinoma in situ, or CIS, was missed on TURBT more than 45% of the time on subsequent radical cystectomy cases. And 86% of residual tumors have been found at the original resection site. With this, it's clear that enhanced visualization is of utmost importance and will be a significant benefit during TURBT.
Furthermore, patient compliance can often be an issue, with only 23% of patients coming back for re-resection. It's therefore all the more important to ensure a complete TURBT The first time, right from the start. Listen to this podcast interview with Dr. Suzanne Merrow, who discusses the benefits of blue light cystoscopy to enhance visualization and ensure a high quality TURBT.
I'm your host today, Dr. Suzette Sutherland, and I'm super excited to have Dr. Suzanne Merrill here today to talk to us about diagnostic aspects of bladder cancer and how to enhance that, specifically with a newer type of technology called blue light cystoscopy. Thanks for being here with us today, Dr. Merrill. It's my pleasure. Thanks for having me, Suzette.
Yeah, let me tell you a little bit about Dr. Suzanne Merrill. She is trained at Duke University for her urology residency and then did a GU oncology fellowship at Mayo Clinic in 2015. She's now 10 years out of fellowship, so she has a lot of experience under her belt. She started on faculty at Penn State Hershey Medical Center. where she was program director there too for the urology residents.
And now since about a few years, since 2021, she's in Colorado at Colorado Urology, which is under a bigger umbrella of United Urology and specializing in GU oncology and also considered a regional bladder cancer specialist. So she really knows what she's talking about here today. And I'm so happy that she's here to share that with us today. Well, thank you. So let's just get started.
Like, first of all, just a couple of, you know, good fun facts, I suppose, not so fun. But, you know, we know bladder cancer, it seems like it's getting even more common today than it was even when I was training. It's quite common, more so in men than women. Tell us the statistics around the epidemiology today.
Yeah, of course. It's a lot more surprising when we're talking to our patients about how common bladder cancer is. So in 2024, it ranks as the fourth most common cancer in men and the sixth most common cancer in the U.S. for both men and women. And so superficial bladder cancer actually comprises of greater than 60% of all our new diagnoses that go on.
And when people get superficial bladder cancer, the main concern is that there is a high risk of recurrence. And that recurrence in just year one can be as high as 60 percent and obviously escalates going forward in time. So this discussion we're going to have today about diagnosing it, getting the right stage and grade done,
And fully taking care of it when we go in for that TURBT is absolutely critical for both our patients and getting them on the right track for treatment.
Right. So we know when we talk to patients about cancer, oftentimes I say the C word before I say the word, right? Because it's so frightening, right? And we as physicians and surgeons know that one person's cancer isn't another person's cancer, especially when we're talking about different organs, right?
But even the case when you're talking about bladder cancer, and we know the earlier you find it, it's totally treatable, right? And when it's late in the diagnosis, it's a whole nother issue for the patients, right? So that's another thing that we're talking about here today, how we can do a better job at detection early. and utilizing some of the newer tools that we have.
Let's look at the AUA guidelines really quickly, right? For the risk stratification, we know it's determined low risk, intermediate high risk, and the things that come into play for that, much of it histological things, and that's where our technology can help us. Can you briefly kind of go into a little bit of the main points that go into our risk stratification today?
Yeah, of course. So really importantly with the risk stratification that our AUA outlines, which is low, intermediate, and high risk, and nowadays we're even talking about a very high risk group that some of us use to really specify patients that are in need of a more comprehensive talk about even entertaining invasive surgery such as cystectomy.
But what goes into the wrist ratification with patients is specifically the stage, so what we gain from that TRBT in terms of the depth of invasion, and then grade, as well as focality, so multiple tumors, and then the size of the tumor plays a role. For example, if we find CIS in a patient, that automatically, that stage, if you will, escalates the patient to certainly the high-risk group.
And then if we have a couple of features such as CIS, maybe also T1, if they have lymphovascular invasion, then a lot of us are thinking such patients should fit into even a higher escalation risk category, such as a very high risk group. And those are the patients that we're really concerned about, not only in terms of recurrence, but very much progression of disease.
Yeah. So it's oh so important to really know the accurate histology, right? At the time of biopsy, at the time of look-see, right? When we take them for a look, cystoscopically, whether it's in the office or in the OR, we want to be really confident that we know what we're seeing, that when we see nothing, as an example, that we really are seeing nothing.
So tell us about the blue light cystoscopy, the cyst view, and how that works and how that enhances our visualization. Yes.
So as you mentioned, definitely the cornerstone for diagnosis is that TURBT. And use of blue light cystoscopy combined with the optical imaging agent called cyst view, and it has a long kind of generic name or kind of chemistry name to it, which I'm not going to even go into here. But ultimately, you put this agent into the bladder, and it interacts with the heme biosynthetic pathway.
And it accumulates in these photoactive porphyrins. And it is these photoactive porphyrins which preferentially accumulate in malignant cells. And then when we use blue light illumination, it's these photoactive porphyrins that then, okay, which are accumulated in the cancerous cells, fluoresce bright pink, okay, under that blue light illumination. And so you're able to visually see that.
where these cancerous cells and conglomerations of these cancerous cells are, where they might not be apparent under white light, and really where this optical imaging agent has kind of shined, if you will, to use that. is in carcinoma in situ cases. So where we know that that disease specifically can be elusive under white light, we can miss it.
This agent really has shown to be uptake specifically in that superficial type of bladder cancer and allows us to visualize it, resect it, even see the margins of our resection to be able to fully resect and evacuate the cancer from the patients at the time of the TRBT.
I've had the opportunity to use this myself and was really astounded at what I saw on white light versus what I then was able to see on blue light. And so it really was an eye opener. The first time I used it was several years ago, but it really was an eye opener.
And I'm a firm believer that it helps with diagnostics at this point and really that, you know, it should be used if possible on almost all patients. What are your thoughts on that? when it should be used? Or is there a time when it shouldn't be used?
Yeah, no, I think it's an important kind of topic to bring up. And it's certainly one of discussion and one of preference. But I will tell you that when this optical imaging agent rolled out, it was FDA approved in 2010. And so it's been around for quite some time.
And initially, we were using it really in patients that we knew already had a diagnosis of CIS, where it really has shown to detect that cancer, actually showing ultimately that it detects it, just to give you some hard data here, detects CIS tumors were found in 34.6%. patients compared to, for example, white light. The CIS tumors were only found in blue light up to 34.6% of the time.
So that's a huge number, right? One third of the patients. And we're talking about something as serious as CIS. Exactly.
And so initially people thought, well, maybe I should only use it for CIS patients. And ultimately, right, we only know a patient has CIS after that first TURBT. And so people would use it in that sort of situation. It was also felt to be a good use in people that had that positive cytology, but that white light surveillance cystoscopy didn't show anything abnormal.
And so you could use it there to see if we could see anything better under blue light illuminescence. But really, as we've used this technology more and more, we're finding that it really has more widespread applications. And it can be used for any resection, for any low-grade, high-grade patient or stage of disease.
I will tell you that when I don't think about using this is in your high volume tumor patients. So where you've gone in there cystoscopically, you know, the first time after the workup and there's just tumor everywhere. You have a hard time seeing normal urethelial walls. It's very hard to navigate kind of around the bladder. that is probably not a great time to use this technology.
But I can tell you, though, using that technology on that patient for the second resection is a great use to make sure that you've gotten all the tumor out of there, that you can see kind of your margins of resection. You know, I think we've all felt, and I'm sure you can agree, Suzette, that we do not do as good of a job with TRBTs as we think we do, right?
We train our residents, you know, very early on with doing TRBTs. Obviously, this is a cornerstone of urology. They need to know how to do them. But many times when we're doing TRBTs, we're with a junior resident, for example. This is kind of the junior resident case.
And unfortunately, the TRBT is so critically important for these patients as, again, it is one of their mainstays of treatment to get that cancer out fully, accurately stage and grade the patient, get them on that right journey. And there is a lot of data out there and we all know it that we do leave tumor behind.
There's reports up to, you know, 76% that residual tumor is left behind after the first TRBT. And that's a high number. And so again, this technology can really help to make sure that we do the best job we can for our patients, you know, at those TRBT settings, initial TRBT, repeat TRBTs, and getting all that cancer out that we can.
It is amazing having trained in the era before blue light and how we thought we were doing such a good job with our two RBTs. And now with the blue light, you see the residual tumor, as you said, that you miss. I mean, I didn't know until doing a little more research myself in anticipation of this podcast how high that number was.
And when you look at the recurrence rates or the residual tumor rate, I mean, as you said, sometimes this can be up to two thirds in some reports, but even how much of T1 disease versus T2 disease gets missed, you know, because the resection isn't done adequately enough just with white light. So up to 15 to almost 30%. So of the residual disease being T1 to T2.
So again, we know this totally changes the The prognosis of the patient, right, and what we're going to do next or what we should be advocating for next. I just wanted to make that point that when we look at the newer, I think they came out in 2024, yeah, just last spring, the AUA-SUO guidelines concerning this.
They actually say in patients with non-muscle invasive bladder cancer, we should be offering blue light cystoscopy. Now they make the caveat, you know, at the time of TURBT, the caveat is if available to enhance detection and decrease recurrence. So it's a moderate grade, grade B evidence strength. But again, they do put that word should in there as opposed to saying should. could, right?
So the data is pushing a little more towards or pointing towards the real potential, the benefits of this blue light imaging.
Yeah, that's very true. I think the data really over time has... shown us that blue light is a technology that should be offered to our patients, that it has good enough evidence behind it, that it can impact our patient's course of disease and outcome.
Even back in 2013, there was a meta-analysis of nine studies, which ultimately showed that detection of TA and T1 lesions may be up to 25% greater with blue light cystoscopy and use of cis-fueled than compared to white light.
And overall, this translated looking at really the raw data from this meta-analysis that the rate of recurrence with use of blue light can be reduced by about 11%, and it can certainly prolong the time to recurrence by about seven-ish months. So some pretty impactful evidence behind this technology.
And then I guess to take it to another direction a little bit, these patients that have mixed, you know, low and high grade histology or uncommon variants, does it help to determine, you know, is it picked up by the uncommon variants as well so it can help to determine these more really high, high risk patients? Yes.
Yeah, no, that's a really good point to bring up. You know, I think at least right now, evidence hasn't really kind of panned out, you know, in regards to it. Does it get picked up by more variant histologies such as small cells, such as micropapillary cells? sarcomatoid, which we all know can be seen. It's more rare, but can be seen certainly in the superficial setting.
These studies, these randomized studies, multi-center perspective in nature that really set this optical imaging agent up for FDA approval and use today didn't really sort out the variant histology, if you will. What we know is that certainly it does get picked up more by more aggressive type lesions like CIS, but can certainly still be used in the low-grade setting.
And as you mentioned, in our superficial bladder cancer, the mixed-grade heterogeneity is up to 30%. And so it's just very important to be able to ensure that we're capturing heterogeneity if you will, the truth about what is in a patient's bladder. Because, for example, with our intermediate risk category of the AUA, that contains patients that are low-grade, okay, as well as high-grade patients.
But
But the recommendations for patients that fall in that intermediate risk category is that the provider, you know, should consider intervesicle therapy. Or excuse me, it says it just should consider intervesicle. it doesn't actually recommend as strongly as if you're in the high-risk category to give intervesical therapy.
So it kind of leaves it up to the provider as to whether that patient should go on further with intervesical treatment or not. And the problem with that, if we've misclassified a patient
and they actually, for example, have a CIS lesion that we missed, or it was a predominantly low-grade papillary lesion that was visualized, but yet you miss that one smaller high-grade lesion sitting in the back of the bladder, smaller, then that patient might not be placed into the right risk category and therefore not receive the appropriate intervesical treatment going forward.
Yeah. Can you refresh my memory? Is there a certain percentage? If it's mixed, is there a certain percentage of high grade to put them into the high grade category, like 5% or is it any high grade?
No. Very good point. You're right. It is actually 5% is only what is needed within the total specimen volume to deem that patient now is high grade.
Well, I mean, that's obviously a very important junction then whether a patient is deemed intermediate versus high, getting intravesical chemotherapy or intravesical BCG, and the risks associated with the intravesical therapy, right?
That clinical decision, taking out, you know, all of the objective things and looking at the patient, having the patient help make that decision, what they're willing to do, it's not easy, right? And so, The more we have on the diagnostic end of things to point our fingers towards a high risk situation to tell us to do the intravascular therapy.
I mean, it obviously makes our job somewhat easier to some degree, right? Because that decision making process is out of it, the judgment part. But also, I think for the patient to accept that. doing intravesical therapy. It's not an easy thing. You do this all the time, right?
This isn't my specialty, but I do have some bladder cancer patients that are women in my practice, and it's never an easy thing for those women to undergo that and some of the hardships associated with the symptoms thereafter and so on and so forth that they go through, right? So this really would help, you know, make that diagnosis. I found some information on the sensitivity.
the accuracy, right? Looking at what's seen through the eye and then what's seen histologically. And with white light, the accuracy is 76% compared to blue light, 91%. And then combination, white plus blue, 98.5%. Now, clearly that comes from, I'm sure, one conglomerate study of looking at things. But still, the difference there is really poignant.
Yeah, remarkable. Definitely. And, you know, I think that gets at the point, too, when we talk about the logistics of using this technology is that you do want to use technology.
both white light and blue light together, that you really should kind of not, you know, kind of only resect under blue light, for example, that you do want to use both kind of information gained from when you're doing your cystoscopy under white light, as well as the information gained under blue light. And that's where you're going to get the best accuracy.
And why do you say that? Is that more for our learning purposes? So then we can go back and say, this is what it looked like in white, and now I see it on blue. So ergo, next time I'm going to know that white light, little distal I didn't think was important, is important, or is there more to it?
Yeah, I mean, I guess there's certainly kind of a learning to it. But I think, again, white light is kind of what has been around historically and traditionally. And it's important that blue light again, how this technology works with SysView and this optical imaging agent and that it accumulates most preferential cancer cells.
It can also accumulate in areas of trauma and areas of inflammation, okay, where you have, again, this kind of increased kind of vascularity and heme biosynthesis taking place and these photoactive porphyrins in high accumulation. So, Ultimately, they've looked at with these pivotal studies kind of what the false positive rate is between, you know, use of blue light and white light.
And there really is not a significant difference between the two. But we do see, again, where the false positives are occurring are occurring at sites of, again, kind of trauma, potentially previous resection sites, especially on the margins. You can see this happen at the areas of scar. Certainly, if there is kind of active inflammation kind of infection is where this can happen.
So it is important to, again, kind of use your judgment compiled together from both the white light and the blue light as to whether or not you decide to take a biopsy, do a full scraping resection.
Because if we think real practically, when we, you know, you put the cyst view in, it They sit there for an hour and it colors the bladder. We'll get into the workflow in a minute, but it colors the bladder. So when you take them to the OR there and put in the scope, it's already all colored. You've lost your white, your absolute white light.
Or do you mean, well, I guess, no, you can still see everything looks still the same on white light or are there differences on white light with the SysView in?
No, there shouldn't be. We can certainly talk about the logistics. It's important. But one of the things when you do, you take that patient into the OR, they have the SysView in their bladder still. You evacuate it after either if they come in with the catheter clamped or if they're holding it naturally.
evacuate it with the catheter, evacuate it with the scope, and then you should actually cycle the bladder with, again, your saline, wash it out, especially if it's sat in the bladder for longer than that recommended dwell time of an hour. It's definitely kind of accumulated more, so the blue light kind of gets a little bit challenging initially unless you cycle the bladder a couple times and look.
But that white light visualization should not be infringed upon because of that you know, optical imaging agent in there.
Okay. That was really the big question. I think sometimes I hear people wonder if it ruins your ability to get a good white light look, but you're saying no, you still get a good white light look and then you turn on the blue light imaging and you get your blue light. Right. Yes. Got it. So let's talk about the workflow a little bit.
Sometimes people think there's too much fuss and muss and can I really do this? And I'm at an institution where it's done quite easily. I think it's just important to get a good workflow going. to be able to do this efficiently and have some trained staff that understand the importance of what you're doing.
So why don't you walk us through what you do when you have a handful of cases maybe stacked or how you make it work for you?
Yeah, no, I think it's really important just to, you know, lose the headache of something which has to be done before, right, you can do surgery on a patient and right before in that pre-op setting. So I think one, you know, for all our listeners, PhotoCure creates a kit, a SysView kit, and really it has everything in there to mix and instill, okay?
You do have to provide a separate, or we provide a separate catheter and Eurojet, But everything is in that SysView kit to use in terms of mixing up, et cetera. And so ultimately, we have created kind of a pre-op order form for our nurses. And we had a full run through in pre-op, kind of a learning session before we kind of rolled this out. at my hospital that I work at. And that has worked well.
And so ultimately, the orders get sent and the nurses now know what to do. The consent is already signed before that patient walks into pre-op. So the nurses have no reason by which to carry out your orders going forward. And ultimately, you know, one of the first questions they ask the patient is, you know, can you hold your bladder, you know, for 30 minutes to an hour?
And if they can, then likely we do not leave a catheter in them clamped. We remove it and they hold it. You really want a 60 minute dwell time post installation for the imaging agent to work well. And you don't want to exceed three hours either. And so because there's at least, you know, about 30 minutes of time, you know, to install.
get the patient and put this drug in, if you will, everything like that. And then you got 60 minutes of dwell time. Sometimes this does not work best as the first case. So something to think about, or you at least allocate your patient flow to maybe come in a little bit earlier. So you can start on time.
But then actually stacking these cases, I think, works pretty nicely, gets the nurses into a rhythm in the pre-op area. But ultimately, once the patient has dwelled for that amount of time, then they come back to the OR, you put your scope in. The scopes, again, that we use with SysView are stored scopes. OK, that has the blue light capability. So that's really important.
So your hospital needs to be outfitted with Storz equipment. This cannot be used with Olympus.
So that was a question I had just to make sure. So there's no other company that makes equipment that will be compatible for this. It's Storz.
That's correct. And I think we can certainly should talk about this some more in that this, I think for, you know, a lot of providers, a lot of groups out there, again, academic centers, you know, has this been kind of one of the, you know, barriers that's felt when thinking about can I, should I incorporate this technology into
into our practice is because if they don't already have Storz equipment, it can be an upfront cost. Can you get into a contract, of course, where you don't have to buy all this equipment upfront? And I will tell you, even nowadays, there are companies that you outsource for lasers, for example.
These companies are buying this equipment and are going to soon be providing this option just like they do the Thulium laser, for example, to different ASCs or hospitals, et cetera, that do not want to buy this equipment outright. So it is going to become more accessible for hospital systems, again, groups that don't want to invest at the outright.
It is interesting. Are there, you know, and it's part of the AUA guidelines and in such a strong way that there aren't more companies that have come down the pike to try and do the same thing, whether it's Olympus or other, you know, there are other imaging companies, right, that do optics. Are there newer ones coming down the pike that you're aware of? No, that kind of fits with this technology.
Not that not that I know of. It's interesting.
Yeah.
Yeah, it really it really is. And I think where why these kind of, you know, third party, you know, groups are, you know, again, purchasing this equipment and again, being offering it is because. Actually, patients are now seeking out this technology. I think it's been around for some time. The evidence is backing it. It's now in our guidelines. More providers are using it. The word's getting out.
It's on or kind of been talked about, described on kind of more national platform organizations that are patient-facing. And so... again, patients are seeking it out.
So I think these companies are getting savvy that they know that it's going to be a used technology and they're going to fit a need where, again, groups might not want to be buying it outright, but they'll use it just like they do these high-priced lasers.
Yeah. And I'm sure as more time goes on, the quality of the imaging will only improve even more. I mean, that's where the technology is going and should go to enhance detection. So back to our workflow, I think we were stacking them in the front end, having your nurses educated, knowing so, you know, the nurse knows what to put in when and timing it and so on and so forth.
You mentioned if somebody can hold their bladder a sufficient amount of time, it's just an in and out catheter to put the CIS view in. But if you have somebody who says, no, I can't, then what do you do?
Then you can leave that catheter clamped. No problem. Just like you do for, you know, our intervesical therapy patients who can't hold their bladder. You can always, you know, leave that catheter in, balloon, you know, balloon up. catheter clamped or a plug and it works just well.
So that really is a very important question to have your pre-op nurses ask because certainly you don't want to, again, use this drug, put it in, and then the poor patient has to go to the bathroom the next 15 minutes.
And it's helpful to put that in your standing orders and the algorithm so you don't get a phone call first thing in the morning always about it, right? You got it. It's an either or and the nurse decides which one to do. Right. So after your TURBT and the OR, you're done. You already said you cycle it through, then you do your TURBT.
Is there any post-op things that are additional because they did the cyst view?
Yeah, no, good question. No, there's not. And I think an important point to make that these pivotal studies revealed is that there really wasn't a difference in side effects that patients had who had undergone cyst view installation, blue light illumination. compared to those patients who just underwent the white light TRBT.
And another important tidbit to know is, too, that you can certainly still use, I have done it, post-op gemcitabine for patients who you feel that that is still indicated on. You can perform retrograde pylograms. So all that stuff you can still do, really. You can carry out your normal, again, interoperative workflow for that patient as it's dictated by their situation.
Another important point is if you're doing this after you've done intervesical induction therapy in a patient, you do want to wait about that six-week kind of time point as shortening it up, certainly taking them back too soon after intervesical therapy and using blue light. That's where you probably can see more false positives happen.
When you're shining that blue light, just because of the inflammation where this optical imaging agent is going to accumulate to is not going to be only in cancer cells.
Yeah. In what time span was that? Recommendation is about six weeks. And then, you know, let's talk a little bit about, too, upward migration of staging and the numbers around that and how blue light has, you know, sort of opened our eyes. We've had a little bit of this discussion, too, but not as much about just really that patients that have low risk
And then suddenly, because of blue light, you're able to get a better visualization, better resection, so on and so forth. Then you found that, you know, there are studies out there showing that, oops, they really seen a trend of upward migration, right? Of more high grade patients out there. Isn't that true? With the use of blue light, as we've looked over the last handful of years or so.
So there, in 2018, Danishman published in Neurologic Oncology some real-world data, which is really helpful to understand, again, you know, outside of the very strict criteria of a randomized trial, you know, how are people using this data and what are the results? And so through a U.S. kind of prospective multi-senator registry, they found that use of blue light
can result in a rate of upstaging of about 14%. And how that breaks down is that ultimately 8% of patients were identified with cancerous lesions, whereas with the white light, they were not. Okay, so that stages them to having cancer. And that 6% of patients actually had an increase in that risk status. What we were talking about before, you know, that vulnerable intermediate risk category was,
Where again, if they were found to have either a high-grade lesion, whereas initial white light resection would have only shown maybe a white low-grade lesion, or they would have found maybe a CIS lesion, then they're popping up into that high-risk category. And therefore, again, would be set on a path of recommended intervesicle therapy after their resection. So really important stuff for sure.
Yeah. So a lot of this, of course, is very helpful for patients that have non-muscle invasive, right, superficial intervesicles. Is there some data to show with the use of blue light, it's really helped us to identify the muscle invasive patients as well? Like upstaging to that level or is that... You know, usually those are patients that have a little bit more burden in them.
They also, their tumors can look a little aggressive even on white light. They've got, you know, and so sometimes we have more of a hunch of that than we do when people just have very small CIS areas or things like that. But I just wonder if the data also shows it's been helping us to identify patients to move them from the non-muscle invasive into the muscle invasive category. Yeah.
Yeah, no, that's a good question for sure. I think the data is more about showing kind of, again, risk migration in the non-muscle invasive categories rather than switching to a kind of T1 to T2 stage, for example. I think it certainly...
This technology really has shown us that it is this CIS, which, as we mentioned before, is a very elusive disease under normal, traditional white light capacity. And that ultimately, historically, we've done a very poor job in detecting CIS.
In 2023, there was a report looking at kind of a cystectomy database and looking at kind of what the path was retrieved from the, you know, whole mound specimen, the cystectomy, compared to what was their, you know, initial, you know, diagnosis from the TRBT preceding the cystectomy. And ultimately, 45% of cases actually missed CIS. So there is CIS in the cystectomy pathology and
none detected in the TRBT.
And so that just gives you a hint that, gosh, if we're missing up to 45% of CIS in patients and that those patients would ultimately be, you know, transitioned, you know, up kind of stage in risk status, if you will, to the high risk category, maybe even the very high risk category, we'd be having different conversations with our patients, ultimately setting them on a completely different, probably cancer journey.
Yeah, that's really amazing. Those numbers are alarming. So I'm thankful that we have something like Blue Light to help us along and look forward to see what's developed even more in the future. There is something else that we can touch quickly just because it is in the AUA SUO guidelines, another form of enhancing detection, but narrowband detection.
imaging or do you have much experience with this? They say you could recommend it to patients. My understanding is there's not a ton of data out there, but it's something maybe to look for in the future to see if there's more enhancement that develops. What can you tell us about that?
Yeah, so narrowband imaging is something we can use on our Olympus scopes. I think a majority of people, you know, perform TRBT with Olympus scopes. And so it's a, again, a kind of, if you will, button kind of toggle switch that you can use to transition images.
to where now we're having kind of blue to green wavelengths, which actually kind of penetrate the superficial layers of the urethelium, allowing better visualization of the microvascular structures. And of course, you know, cancer structures have more microvascular structures to them. So they're going to kind of show a little bit more enhancement under NBI.
I think the benefits of NBI is that certainly there's no pre-drug. It's just, again, a flip of a switch, a button pushed on the monitor. You can, again, use it during surveillance as well, just with, again, like a button push on the scope. And, you know, what the AUA says here, and I think they're very cognizant of kind of our resources, right? So,
They know that NBI technology is more readily available to clinicians than blue light might be. And so they put it out there as a grade C recommendation. You can consider using this to increase detection. decrease recurrence, but they fully acknowledge that really there doesn't appear to be proven evidence that it decreases recurrence, okay?
But there's really no additional kind of risk incurred by the patient, incurred by the operator using it. But ultimately, with, you know, kind of systematic reviews being done on NBI versus white light, Really, there's only been one that has shown an improved kind of decrease in recurrence with NBI. The other three have shown really no difference in recurrence.
Is it really that there aren't many studies out there yet because it's too new? Or is it really that there's enough data just when we look at the data, there doesn't seem to be much benefit? I think it's the latter. I think it's the latter because it's been around for quite some time. Well, it's good to touch on it. It is in the guidelines.
And so I know people think about that now and which one should I do? And as you say, I've been exposed to that as well with Olympus and it is a lot easier, right? But we also have to recognize if it's limited with respect to what it can provide us, then there might be a reason to do the extra steps of the blue light, needless to say. Yeah. Good. Exactly.
Well, I think this has been a very healthy discussion about non-muscle invasive bladder cancer and the management thereof and enhancing our diagnostics and helping us to determine what algorithm to use to treat, right? Risk, low risk, intermediate risk, high risk. Well, great. Well, this has really been so informative. Very, very helpful.
Again, Dr. Suzanne Merrow from Colorado Urology, really an expert in urology. GU Oncology in general. She has more than just bladder cancer, but has really become a regional expert in her area for bladder cancer. And we're so happy that you were here with us today to share your expertise with us. Thank you so much. You're so welcome. It was my pleasure.
So once again, thank you for joining us on Backtable Urology. We strive to be your source of information for all things urology. Again, I'm Suzette Sutherland signing off. See you next time.
Thank you so much for listening. If you haven't already, make sure to subscribe, rate the podcast five stars, and share with a friend.
If you have any questions or comments, DM us at underscore Backtable on Instagram, LinkedIn, or Twitter.
Backtable is hosted by Aditya Bagrodia and Jose Silva.
Our audio team is led by Kieran Gannon, with support from Josh McWhirter, Aaron Bowles, Nick Shellcross.
And Ness Smith-Zavidoff. Design and digital marketing led by Brian Schmitz. With support from Devante Delbrun. Social media and PR by Chi Ding. Administrative support provided by Jamila Kinabru.
Thanks again for listening and see you next week.