New bladder cancer screening tool detects more tumors in early stages

MD Anderson Cancer Center
Date: 06-17-13

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Lisa Garvin: Welcome to Cancer Newsline. A podcast series from the University of Texas; MD Anderson Cancer Center. Cancer Newsline helps you stay current with the news on cancer research, diagnosis, treatment and prevention. Providing the latest information on reducing your family's cancer risk. I'm your host, Lisa Garvin. And today our guest is Dr. Ashish Kamat. He is an Associate Professor of Urology here at MD Anderson. And we're going to talk about a special form of cystoscopy that we've been using here at MD Anderson with great success. Dr. Kamat we are going to be talking about Blue Light Cystoscopy, which is maybe commonly known as Cysview. First of all, walk us through what is a cystoscopy? And how is it used to diagnose bladder cancer?

Dr. Ashish Kamat: Sure. So a cystoscopy is essentially a look inside the bladder. The bladder is a hollow organ and the way we look at the tumors inside the bladder is by putting a scope through the urethra, either in male or female patients, and then visualize the inside of the bladder. So that's what a cystoscopy is.

Lisa Garvin: And typically you use some sort of contrast that the patient drinks to highlight certain structures, correct?

Dr. Ashish Kamat: Actually no. A cystoscopy, as it exists today, has been around for many, many decades. The only thing that has truly changed in a cystoscopy is the quality of the optics. So in many decades ago we used literally a light bulb at the end of mirrors to look in the bladder. That changed. With the development of fiber optics we have fiber optic channels that we use to look at the inside of the bladder. And over the last maybe 4 to 5 years, the most dramatic improvement short of cystria -- which I'll touch upon -- has been going from standard definition screens to high definition screens. Now the fluorescent, Blue Light cystoscopy that you referred to, that is a major improvement in the way we look for tumors, and that's the only place where we actually use contrast to evaluate the bladder.

Lisa Garvin: Is cystoscopy a common tool for bladder cancer diagnosis? Do most patients get a cystoscopy?

Dr. Ashish Kamat: Absolutely. If a patient presents with blood in the urine, one of the things that we always have to rule out is a tumor in the bladder. And as part of the standard workup, a cystoscopy is an essential part of the pathway the patient goes through. So it is a standard, diagnostic technique to evaluate the inside of the bladder.

Lisa Garvin: And when we're using Blue Light cystoscopy and contrast, how recent is that development?

Dr. Ashish Kamat: This particular technology has been available in Europe for almost a decade. It's relatively recent in the United States because it was only approved by the FDA about 3 years ago. Our center, MD Anderson, did some of these enrolled study -- or enrolled some of the [inaudible] patients to get this approved here by the FDA. Now in Blue Light cystoscopy, we still rely upon cystoscopy as in visualizing the inside of the bladder. But the advantage here is that we have molecular diagnosis. So in other words, the patient has this contrast material that's put in the bladder about an hour before we take a look in the bladder with a cystoscope. And the tumor cells or any other rapidly dividing cell, most commonly cancer, will take up this particular agent and metabolize it. And then during cystoscopy we usually look around with a white light -- which is standard white light that's available in the environment. And after that you turn on a special light -- essentially the blue light. That's why it's called Blue Light cystoscopy. And under this blue light the tumor cells that have taken up the contrast, they shine bright pink. In other words it's like a neon sign saying, here I am. Here I am. So it does improve the accuracy of cystoscopy, especially amongst physicians who may not be quite as experienced at cystoscopy, who might need that extra visual aid.

Lisa Garvin: And aren't there issues with the bladder lining? Isn't it a fairly smooth lining and it can hide like microscopic disease pretty easily?

Dr. Ashish Kamat: Absolutely. The bladder lining is smooth, as you mentioned, and you can't see tumors that are too small to be seen with the naked eye. Of course even there the experience of the urologist plays a big part in how accurate cystoscopy is, but that's another advantage of a tool such as fluorescent cystoscopy. Because tumors that are too small to see with the naked eye will light up. And often times what happens -- and we find this when we're, you know, training people on it, it lights up pink. And then when you pay closer attention to it, you go, ah-ha! I can see that with the white light too. So it does highlight areas that may not be quite as visible to the naked eye.

Lisa Garvin: Because I have seen the before and after pictures with the white light versus the blue light, and it is quite arresting, I mean the change.

Dr. Ashish Kamat: It can be. Absolutely. When I show patients pictures of their tumors sometimes, even they go, I could see the doc! [Chuckles].

Lisa Garvin: And it seems like a simple concept, but I mean it does. I mean okay, let's try like fluorescence. Where was the germination for this great idea?

Dr. Ashish Kamat: Well actually if you go back into the history of this ability to try and identify tumors based on visual and color properties, that's been around for many decades. We would try to put certain vital stains in the bladder; hope that the tumor takes it up. And actually you can use something that's very cheap; put it in the bladder. It's not very accurate though. So we don't use vital stains such as methylene blue anymore. The concept for this fluorescent diagnosis came about with the understanding that tumor cells are different from normal cells. They have certain enzymes. In this case it's a preferring metabolizing enzyme. And using that property we were able to develop this technology.

Lisa Garvin: How long have we been doing it here at MD Anderson?

Dr. Ashish Kamat: At MD Anderson we've been doing it for a little over 2 years now.

Lisa Garvin: And have you collected any data or seen any results that found that you've been able to give a better diagnosis? A more accurate diagnosis?

Dr. Ashish Kamat: Oh absolutely. And it's not just our data, actually we were part of a multi-center group that looked at this, and we -- and others -- have shown that using this special diagnostic tool we can not only detect more tumors at the first diagnosis itself. So in other words we miss less tumors in patients when they show up with the initial diagnosis, but -- and it makes sense, if you detect more tumors early on and you take care of them early on, you decrease the number of times a patient will have a recurrent tumor. So in other words, if there are 10 patients we are able to pick up tumors in more patients out of that 10. But within the patients that already had tumors detected by the white light, we are detecting more tumors per patient and thus treating them better. So it's better for the population and the patient.

Lisa Garvin: Have you found that maybe -- and this may be not something you've looked at in this study -- were you able to spare more people's bladders because of better diagnosis of their tumors?

Dr. Ashish Kamat: There is a hint that using this technology might end up sparing more bladders. In other words, enable us to save more patients from having to undergo the radical cystectomy, which is where we take out their bladders. This is data that was presented at our national meeting 2 years ago. Dr. Bart Grossman, one of my colleagues presented that. It wasn't statistically significant, and that's mainly because you need a huge number of patients to show statistical significance. But yes. There is -- you're absolutely right. There was a trend towards us being able to spare more people from having to have their bladders taken out.

Lisa Garvin: Now typically with bladder cancer, is this a cancer that is caught early typically? Or is it more advanced when diagnosed?

Dr. Ashish Kamat: There are about 74,000 cases of bladder cancer in the US every year. And fortunately the majority of those are picked up at an earlier stage where you could potentially save the bladder. So that's the population in whom this is most useful. It does tend to be that women have their cancers detected later as compared to men, and that's mainly because one of the presenting symptoms of bladder cancer is irritative symptoms or blood in the urine. And many women, unfortunately, are told by their primary care physician -- right or wrong that's debatable -- but they're told it's likely an infection. Go ahead and treat it. Take an antibiotic, but don't undergo the actual formal workup for a bladder cancer.

Lisa Garvin: Now Blue Light cystoscopy is not a standard of care yet is it?

Dr. Ashish Kamat: It should be. It should be the standard of care. It is technology that has been available in Europe. In fact they consider it standard of care over there for their patients. It has recently been available in the United States. The FDA says that it's an adjunct to use in all patients that have papular tumors either suspected or known. And I believe just the same way you would not want to watch standard definition television today, when you have clearer picture, you should not sacrifice the ability to diagnose tumors more accurately just because you don't have the equipment. Now of course that's a practical and logistic matter as well, and how that gets solved remains to be seen, but it should be standard of care for us to provide our patients with the best diagnosis of their cancer.

Lisa Garvin: It doesn't seem to me though that it would be a fairly big learning curve for urologists or other doctors to perform this procedure. Is it much of a curve?

Dr. Ashish Kamat: No. No. It's actually quite simple. When I train my trainees on the technology, it takes them maybe 1 or 2 instances, after which they themselves are able to identify these tumors. It's not a very complicated procedure; it's just that you do need new equipment. It doesn't work with existing light because you need the special blue light to make it work.

Lisa Garvin: So what if a patient sees this information on the web and they say, I want Blue Light cystoscopy? How do they go about -- I mean because they may go to a doctor that says, I don't know what you're talking about. Or we don't have that. If somebody really wants this, what would they do?

Dr. Ashish Kamat: Well it's interesting you mention that because I have a lot of patients that actually will call my office and ask for me and want to see me because they've read about this on the internet, or they've gone to the patient advocacy websites and seen where this is beneficial. And of course, if they call me and say, can I come see you? I say, of course. You know, we have it here at MD Anderson. We're more than happy to take you on as a patient and use this. The patients obviously can't travel sometimes, and there are regional centers of excellence scattered throughout the country now that have this technology. So they could go to any local center where they have Blue Light. Clearly it hasn't penetrated the community yet, so it's a question patients should be asking the urologist. You know, simply, will you be using Blue Light to evaluate my bladder.

Lisa Garvin: Who would be the typical patient who would be the best candidate for Blue Light cystoscopy?

Dr. Ashish Kamat: So the typical patient or the ideal patient for Blue Light cystoscopy would be anybody that has a known tumor in their bladder, or a suspected tumor in their bladder that is undergoing a procedure to have this tumor taken out. And that honestly ends up being almost 100% of patients that present with a diagnosis of bladder cancer. Now of course, 100% is a broad -- you know, a number, and it's never really accurate to say that this technology should be used for everybody, and that's why we have certain guidelines that we put -- you know, posted on our website and other websites that help urologists that are starting out using this technology to better select their patients. But honestly it's a good technology for almost every patient that has a diagnosis of bladder cancer.

Lisa Garvin: Do you feel like it could make the leap as a screening tool? I know there are no real screening tests for bladder cancer, but could we conceivably see that in the future?

Dr. Ashish Kamat: I don't think so. Because in order for this to be used, the patient has to undergo a cystoscopy. And it's very hard to justify the use of cystoscopy as a screen for patients with bladder cancer. So that's the next step maybe if the invasiveness and the cost goes down considerably, we might be able to use this as a screening for bladder cancer. But unfortunately right now just the way it is, it would not be practical for patients to undergo the invasive procedure just as a screen.

Lisa Garvin: And can you walk us through a typical cystoscopy procedure? Explain, you know, how it's done and you know, what the steps are in a procedure?

Dr. Ashish Kamat: Sure. So the way a cystoscopy is done, it could be done under local anesthetic or it could be done under general anesthesia. Essentially, under local anesthetic, the patient comes to the office. We have a little lidocaine jelly that's inserted into the urethra. Left in there for about 15 minutes or so. And after that we use a flexible scope that's very -- it's smaller in size, and that's the technology that's allowed us to do that -- and look inside the urethra and the prostate in men, and then look inside the bladder. A lot of patients are more familiar with the term, colonoscopy. This is similar. Although it's a much smaller scope and a completely different place we're looking. Now if you use fluorescence cystoscopy, there's a step before the cystoscopy where we put a catheter in the bladder and put in this medication in the bladder. We take the catheter out and the patient holds the medication in the bladder for about an hour and then after that, the procedure's almost the same. Except now after we've looked around with the white light, we switch on a light and look around with a blue light.

Lisa Garvin: What do you see for the future of blue light cystoscopy?

Dr. Ashish Kamat: Two things. Number one I would hope that it gets adopted by more urologists and that more patients benefit from this technology. And the second would be the ability to use the fluorescent cystoscopy with flexible scopes. Because the way it is currently, in order to do Blue Light cystoscopy, we have to use a rigid scope with the way the optics are. I know there are companies over the -- all over the world that are working on technology to make it more available with flexible scopes so it would be more comfortable for the patient.

Lisa Garvin: Great. Any final thoughts?

Dr. Ashish Kamat: No. Thank you for having me.

Lisa Garvin: Thank you. If you have questions about anything you've heard today on Cancer Newsline, contact MD Anderson at 1-877-632-6789 [music]. Or online at mdanderson.org/ask. Thank you for listening to this episode of Cancer Newsline. Tune in for the next podcast in our series.

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