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SPECIAL REPORT

Diagnosing Bladder Cancer During Cystoscopy Cystoscopes Have Advanced a Long Way The Sooner the Better The Challenges of a Resilient Condition The Quality of Light Weighing Up the Factors and Making a Decision

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INCREASE DETECTION, REDUCE RECURRENCE

28%

Visualises 28% more carcinoma in situ

17%

Detects bladder cancer in 17% additional patients

17%

Reduces risk of recurrence to 17% at one year Compared to WLI Source: http://www.ncbi.nlm.nih.gov/pubmed/23113702 © 2012 The Japanese Urological Association, International Journal of Urology (2013) 20, 602-609

NARROW BAND IMAGING For Non-Muscular Invasive Bladder Cancer Learn more by visiting our online NBI Portal. www.nbi-portal.eu/en/uro

Excellent view of mucosal and vessel structures even with white light.

KeyMed House, Stock Road, Southend-on-Sea, Essex, SS2 5QH, UK +44(0)1702 616333 | www.olympus.co.uk

NBI filters the white light and improves contrast of mucosal and vessel structures.

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OlympusMedicalEurope

@OlympusMedUKIE

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SPECIAL REPORT: DIAGNOSING BLADDER CANCER DURING CYSTOSCOPY

SPECIAL REPORT

Diagnosing Bladder Cancer During Cystoscopy Cystoscopes Have Advanced a Long Way The Sooner the Better

Contents

The Challenges of a Resilient Condition The Quality of Light Weighing Up the Factors and Making a Decision

Foreword

2

John Hancock, Editor

Cystoscopes Have Advanced a Long Way Olympus UK

3

A Cystoscope and What It Does Narrow Band Imaging Improves Detection Rates

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Not Only Detection Reducing Recurrence

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Traditional Approach and Current Improvements

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Future Objectives

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John Hancock, Editor

Publisher Kevin Bell Business Development Director Marie-Anne Brooks Editor John Hancock Senior Project Manager Steve Banks

The Sooner the Better

6

Prevalence of Bladder Cancer in the UK Causes of Bladder Cancer Symptoms of Bladder Cancer Survival Rates

The Challenges of a Resilient Condition

8

Camilla Slade, Staff Writer

First, the Diagnosis

Advertising Executives Michael McCarthy Abigail Coombes

Treatment for Bladder Cancer

Production Manager Paul Davies

The Quality of Light

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Peter Dunwell, Medical Correspondent

Time and Cost

10

Improving Resource Usage and Speeding the Process with Best Practice Guidelines

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The Light Used in Cystoscopy Narrow Band Imaging

Weighing Up the Factors and Making a Decision

12

John Hancock, Editor

Key Factors in Choosing Bladder Cancer Diagnostic Tools The Future Outlook for Cystoscopy

References 14

Š 2018. The entire contents of this publication are protected by copyright. Full details are available from the Publishers. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical photocopying, recording or otherwise, without the prior permission of the copyright owner.

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SPECIAL REPORT: DIAGNOSING BLADDER CANCER DURING CYSTOSCOPY

Foreword

I

t isn’t possible to write about a subject such as

of all, patient. We then review some of the statistics

cystoscopy without writing about the area in

by which bladder cancer’s impact is assessed,

which it is used, in this case, bladder cancer. The

what might cause it and how survival rates might

cystoscope is not so much a front-line tool but is

be improved. Camilla Slade then drills down into

the front-line tool for the detection prior to diagnosis

that to look at how bladder cancer is detected

of bladder cancer and for the surgery with which

and diagnosed and how it might be treated, plus

most bladder cancer is treated. A lot rests on

takes a brief look at the cost side of the equation.

this device being able to do its job as well as the

Peter Dunwell’s article focuses on probably the

best technology will allow. Neither is it possible

most important component in any successful

to separate the tool from the system in which it

cystoscopy – the light used to view inside the

operates which, in the case of bladder cancer,

bladder. He considers traditional lighting and some

does not deliver as good outcomes for patients

exciting new developments that will not only help

as most clinicians would wish. So, in this Report

to detect bladder cancer sooner and with a greater

we consider not only the device itself but also at

success rate, but also improve the success rates for

patient experience, the system within which it works

surgery. Finally, we try to put down a few pointers to

and at the levels of expectation or otherwise which

what could be considered as part of a cystoscope

could be enhanced by the use and improvement

purchasing decision; the material factors and what

of the cystoscope.

the future holds for this very important process.

The opening article considers how the instrument works and highlights some modern upgrades that can improve its effectiveness for all parties concerned, clinician, healthcare system and, most

John Hancock Editor

John Hancock, an Editor of Hospital Reports Europe, has worked in healthcare reporting and review for many years. A journalist for more than 25 years, John has written and edited articles, papers and books on a range of medical and management topics. Subjects have included management of long-term conditions, elective and non-elective surgery, wound management, complex health issues, Schizophrenia, health risks of travel, local health management and NHS management.

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SPECIAL REPORT: DIAGNOSING BLADDER CANCER DURING CYSTOSCOPY

Cystoscopes Have Advanced a Long Way Olympus UK

T

HE CHALLENGE for clinicians in dealing with bladder cancer are, as with all cancers, being able to detect a tumour as early as possible, detecting all tumours to their full extent and, where a resection is required to remove a tumour, making sure that the whole of the affected tissue is removed to minimise the chance of recurrence. The tool used by clinicians in this area of practice is the cystoscope and the process is cystoscopy. Given its importance in the detection and treatment of bladder cancer, at Olympus we are aware that any technology or developments that can be harnessed to improve the ease of use and effectiveness of the cystoscope will be welcome to patients and the clinicians who treat their condition.

A Cystoscope and What It Does The cystoscope has been with us since as early as 1826 and has evolved through that time. Without going back as far as the origins, there have been important developments in recent times. Older fiberscopes consisted of a number of optical fibres with, at one end, the viewing head of the scope which went inside the bladder to build up an image viewed using an eyepiece that could be seen by one person at a time. As the device evolved, a camera head was added to the viewing head and plugged into a camera system transmitting the image to a small standard definition (SD) screen. From just the surgeon seeing into the bladder, there was now an SD image on a screen, but still a small screen. This type of screen and darker image still has limitations in terms of detection capability and training because still only one person at a time can really see what is in the bladder. And while the camera was an advance, the image is subject to the moiré effect, the slight texturing of an image transmitted through multiple optical fibres: it also uses a halogen light source giving a warmer light but typically having a 300 hour lifetime which is expensive to replace.

These days, the latest Olympus systems have advanced to offer a fully integrated HD system with an HD screen. They also incorporate narrow band lighting (see below) and the latest cystoscopes are equipped with an LED light source, with a typical working life in excess of 10,000 hours – a big improvement over the halogen light. Bearing that in mind, it’s worth considering what matters for a cystoscope. The key issues are flexibility, to allow the examining and operating surgeon to see as many areas of the bladder as possible, light, quality of image and size of screen, not only to deliver the best possible detail of the area being examined to support optimum detection and diagnosis but also so that clinicians can discuss the condition in real time with a shared view of the area of concern. Flexibility goes hand in hand with ease of access – the material used and the size of the cystoscope both contributing to ease of access and to patient comfort.

Narrow Band Imaging Improves Detection Rates The aspect of cystoscopy that we want to consider more closely here is the image. Thinking of cystoscopy in an outpatient setting, there would be a camera system as part of a flexible cystoscope that allows the clinician to enter the patient’s bladder and view. Within the camera system, there will be a light source. Typically, cystoscopy would have been carried out using white light to make a bladder map looking for suspicious areas. However, the development of narrow band imaging has added to the imaging process with an optical enhancement technique that improves the ability to spot areas of concern within the bladder and can be used in conjunction with the flexible cystoscope to help detect suspicious areas or lesions. It might not be possible after a first cystoscopy to say definitively ‘that is a bladder cancer’ but narrow band light shows clinicians more of the areas where they need to investigate further.

INCREASE DETECTION, REDUCE RECURRENCE

28% Visualises 28% more carcinoma in situ Source: http://www.ncbi.nlm.nih.gov/pubmed/23113702 © 2012 The Japanese Urological Association, International Journal of Urology (2013) 20, 602-609

Learn more by visiting our online NBI Portal. www.nbi-portal.eu/en/uro

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SPECIAL REPORT: DIAGNOSING BLADDER CANCER DURING CYSTOSCOPY

Narrow band imaging has added to the imaging process with an optical enhancement technique that improves the ability to spot areas of concern within the bladder and can be used in conjunction with the flexible cystoscope to help detect suspicious areas or lesions

At the touch of a button, the specialist or nurse or whoever is using the system can cause an optical filter to come across the white light source in the camera system; this is effectively a narrow band filter that eliminates particular wave lengths leaving just blue and green, which enhances the contrast of the blood vessels in the mucosa and sub-mucosa of the bladder. Narrow band imaging helps the clinician to see vascular structures much more clearly if the user is trying to detect, say, capillary tumours, typically characterised by sporadic or clusters of blood vessels. The whole concept is to improve the visual contrast, allowing the user to see areas that they might not necessarily have seen before, take a biopsy and send that to pathology. Narrow band imaging highlights areas of concern for further investigation. This is where Olympus has worked to develop cystoscopes to the latest standards using narrow band imaging and displaying images in high definition.

Not Only Detection The benefit of narrow band imaging is to increase detection rates but also to reduce the recurrence rate for bladder cancer. The International Journal of Urology1 published a meta-analysis of seven different studies covering 1040 patients in all, in which, “The objective was to evaluate the diagnostic accuracy of cystoscopy assisted by narrow-band imaging compared with white-light imaging for non-muscle-invasive bladder cancer.” The results were significant showing that 28 percent more carcinoma in situ are detected with narrow band imaging as opposed to white light and that carcinoma were detected in 17 per cent more patients using narrow band imaging than with white light: also that recurrence of bladder cancer at one year was reduced by 17 percent in a comparison. 4 |WWW.HOSPITALREPORTS.EU

The conclusion of the meta-analysis was that, “Cystoscopy assisted by narrow-band imaging detects more patients and tumors of non-muscle-invasive bladder cancer than white-light imaging, and it might be an additional or alternative diagnostic technique for non-muscleinvasive bladder cancer.” While it is not the case that every time a cystoscopy is undertaken using white light, something will be missed or that narrow band imaging will always detect tumours that were not previously seen, the latest Olympus cystoscopes are about providing the reassurance and, in most cases where something might be missed, narrow band imaging will stand a better chance of highlighting it.

Reducing Recurrence We are always alert to what clinicians are thinking and to the reality that bladder cancer is one of the most recurring cancers, even following ‘removal’. The process is, if a patient has symptoms such as haematuria (blood in the urine), they might be sent to have a cystoscopy to look into the bladder to determine whether there’s anything suspicious and whether a biopsy sample should be taken. If that comes back as potentially cancerous the patient will then have another test, followed by a TURBT (transurethral resection of a bladder tumour) followed by further cystoscopies until it can be confirmed that there has been no recurrence. However, TURBT it is a challenge for the surgeon to ensure that they have detected the entire tumour and then removed it or that it hasn’t then reseeded elsewhere in the bladder. In either case, the chances of recurrence are high. Not only can narrow band imaging improve early diagnosis, as we have seen, by making it easier to see tumours at an early stage when they will be less obvious


SPECIAL REPORT: DIAGNOSING BLADDER CANCER DURING CYSTOSCOPY

INCREASE DETECTION, REDUCE RECURRENCE

under white light, it can also help ensure that surgery removes more of the detectable spread of a tumour. Narrow band imaging (NBI) used in the theatre during a resection helps the surgeon better see the entire boundaries of a bladder cancer for the resection to remove the whole cancer. That reduces the likelihood of recurrence. Not using narrow band in theatre could limit a surgeon’s ability to remove all that was visible.

Traditional Approach and Current Improvements So, as can be seen above, from a technology point of view, things have changed in cystoscopy in the past few years, especially with the cystoscopes themselves and the technology that they use. But it isn’t an evolution of technology for technology’s sake: it’s all about what can be seen and how well it can be seen. In other words, it is the patient that matters – their comfort during examination and their prospect of remaining clear of recurrence in the long-term

Benefits for the patient from using the latest Cystoscope From the point where a patient reports symptoms, through to therapy and outcomes could be a period of months, with follow-up at, say three or six month intervals. Here, there is benefit from having consistency in the technology used throughout the process. For instance, if a much older fiberscope is used initially, producing a dark image and only one person at a time is able to use it and view the image, and then the followup six months later is conducted with a newer device producing a bright HD NBI picture, that might detect something that was missed during the earlier examination and treatment, which would mean further treatment which could otherwise have been avoidable.

Benefits for clinicians from using the latest Cystoscope The latest cystoscopes from Olympus are equipped for HD images and use LED light sources and NBI whereas older devices would have used a fiberscope with possibly a halogen light source. The move to an LED light source delivers a more natural and brighter light with over 10,000 hours of life, i.e. it’s unlikely to need replacement. But the key thing is the picture of the bladder going from an enclosed, darker, smaller screen to a much bigger, brighter HD screen that everybody can see. This is a huge advantage in every respect including training urologists where several students and the teaching clinician can all view the same image at the same time. New systems also allow teaching clinicians to record a cystoscopy examination to be used as training material. And there is an advantage to being trained using the latest equipment so that using it becomes a natural process.

Future Objectives Future developments should have a number of factors in mind, over and above the capability of the system to do its job to the highest quality possibly with the technology of the time, which should be a given. A prime consideration will always be the comfort of the patient; as technology progresses, the scope will continue to become slimmer, which will improve patient comfort during access; but, at the same time, we’d expect the working parts of the device to become smaller and the image to further improve. The bottom line is to aim to ensure that what the clinician is looking for will be detected at the earliest point and that nothing is missed. Anything that will enhance that process whether by improving visual capability or usefulness in training will represent a good future development.

17% Reduces risk of recurrence to 17% at one year Source: http://www.ncbi.nlm.nih.gov/pubmed/23113702 © 2012 The Japanese Urological Association, International Journal of Urology (2013) 20, 602-609

Learn more by visiting our online NBI Portal. www.nbi-portal.eu/en/uro

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SPECIAL REPORT: DIAGNOSING BLADDER CANCER DURING CYSTOSCOPY

The Sooner the Better John Hancock, Editor Bladder cancer is less likely to have spread and more likely to respond to treatment if caught early

The earlier it can be diagnosed and the more comprehensive the detection that leads to diagnosis, the more limited the cancer will likely be, the more effective the treatment and the better the prognosis

B

LADDER CANCER grows in the bladder lining and, untreated, can spread to other parts of the body such as the lungs, liver, and bones. There are several types of bladder cancer but 90% of those diagnosed with the condition have urothelial carcinoma, i.e. cancer in the cells that line the bladder wall. Within that group, about 80% have ‘non-muscle invasive’ cancer which has not yet grown beyond the bladder into the surrounding muscle: the remaining 20% have muscle invasive – often the result of a late diagnosis. With over 100,000 people currently affected, bladder cancer is the UK’s 7th most common cancer and the 4th most common among men. Over 10,600 people each year are diagnosed with bladder cancer in the UK and, shockingly, 50% of those will die. It also has the highest recurrence rate of any cancer (up to 80%) and is the only ‘top ten’ cancer for which the rates of prognosis are getting worse. Perhaps that’s because it receives less than 0.6% of dedicated research funding (2013-2014) and yet, at £65 million annually, it is one of the most expensive cancers for the NHS to treat. All of these statistics were gathered by Action Bladder Cancer UK2. To try and assess the true cost of this cancer, European Urology3 undertook a cost of illness study across the EU to assess the economic impact of bladder cancer. This revealed that, in the UK, total healthcare cost is 5 per cent of the total healthcare budget. On one aspect of this cancer, all the experts seem to agree, as with all cancers, the earlier it can be diagnosed and the more comprehensive the detection that leads to diagnosis, the more limited the cancer will likely be, the more effective the treatment and the better the prognosis for the patient.

Prevalence of Bladder Cancer in the UK Cancer Research UK has assembled a range of statistics on UK prevalence or incidence of bladder cancer4. These show that 72% of cases are men while only 28% are women, which ties with the figures above. They also show that, while England (17.4) and Scotland (17.7) conform to the 6 |WWW.HOSPITALREPORTS.EU

UK rate of 17.4 cases per 100,000 of population, Wales is significantly higher at 21.6 while Northern Ireland is lower at 16.1. Also, from these statistics, Asian and black ethnic groups have significantly lower rates of bladder cancer than is the case in the white population. As with other cancers, there is a strong association between advancing age and incidence of bladder cancer: in 2013-2015 on average each year almost 6 in 10 (55%) of new cases were in people aged 75 and over. There are strong correlations between lifestyle choices, other health problems, and bladder cancer. As with all cancers, smoking and excessive alcohol consumption are believed to increase the risk of bladder cancer and conditions such as diabetes and liver disease seem to make patients more vulnerable but, as the figures usually relate to all cancers, it might be better to wait for some specific research in this field. There are several complications that can accompany bladder cancer and they have been usefully assembled by Patient5. I won’t list them all here but the one with which most people will be familiar is urinary retention, which can be both painful and, because of its nature, can also adversely impact a patient’s mental health.

Causes of Bladder Cancer The immediate cause of bladder cancer is, “… changes to the cells of the bladder. However, the exact cause remains unknown but there are a number of risk factors linked to the disease. It’s often linked with exposure to certain chemicals, but the cause isn’t always known.” So, says NHS Choices6. The article continues to list several factors that have been identified as increasing the risk of bladder cancer. As the prevalence and incidence statistics (above) show, growing old increases the risk although there’s little that can be done about that. Smoking, as mentioned above, certain industrial chemicals (estimates are that these might account for c25% of cases), occupations in sectors such as dyes, plastics, leather tanning and more, taxi and bus drivers (through their regular exposure to diesel fumes). Many of these are now subject


SPECIAL REPORT: DIAGNOSING BLADDER CANCER DURING CYSTOSCOPY

INCREASE DETECTION, REDUCE RECURRENCE

COPYRIGHT BY OLYMPUS EUROPA SE & CO. KG

to regulations about exposure, but cases from before the regulations continue to arise. There’s also a likelihood that treatment for other cancers (Chemotherapy and Radiation) near the bladder might increase the risk of bladder cancer, untreated bladder stones and even an early menopause might raise the risk for a woman. Again, Cancer Research UK7 provides a neatly tabulated taxonomic list of the risk factors.

Symptoms of Bladder Cancer If the causes are less than absolutely clear, the symptoms are more easily identified. Patient (see above) tells us that the main presenting feature is “painless haematuria [blood in the urine, even when that is not every time one urinates] that is gross in 80-90%.” NHS Choices8 adds that patients might need to urinate more frequently and more urgently, and suffer a burning sensation when passing urine. If ignored, these can develop to pelvic pain, bone pain, weight loss or swelling of the legs. The article leaves no doubt about one

thing, “If you ever have blood in your urine – even if it comes and goes – you should visit your GP, so the cause can be investigated.”

Survival Rates Although men are more likely than women to suffer from bladder cancer (see Prevalence above) “One-year and five-year relative survival rates from bladder cancer are significantly higher in males than in females…” explains the national cancer intelligence network (NCIN)9. Yet again, Cancer Research UK has assembled and organised bladder cancer survival statistics10 which show that 77% of men survive bladder cancer for at least one year and 57% for at least five years: for women the respective figures are 62% and 46%. As must be clear by now, the key issue with bladder cancer, as with any cancer, is the importance of early detection and diagnosis. The following articles will look at ways that can be achieved.

17% Detects bladder cancer in 17% additional patients

The key issue with bladder cancer, as with any cancer, is the importance

Source: http://www.ncbi.nlm.nih.gov/pubmed/23113702 © 2012 The Japanese Urological Association, International Journal of Urology (2013) 20, 602-609

of early detection and diagnosis Learn more by visiting our online NBI Portal. www.nbi-portal.eu/en/uro

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SPECIAL REPORT: DIAGNOSING BLADDER CANCER DURING CYSTOSCOPY

The Challenges of a Resilient Condition Camilla Slade, Staff Writer Diagnosis, treatment and economics of bladder cancer

The more of the tumour that is detected with the first cystoscopy and the more that is removed during the subsequent operation, the less likely the cancer is to recur

B

LADDER CANCER patients, “… with intermediate-risk non-muscle-invasive bladder cancer should be offered cystoscopic follow-up at 3, 9 and 18 months, and once a year thereafter. Those people with high-risk non-muscle-invasive bladder cancer should be offered cystoscopic follow-up every 3 months for the first 2 years, then every 6 months for the following 2 years, then once a year thereafter.” The cystoscope is a very important component in the follow up process for bladder cancer according to that analysis by Patient11. The reason is elsewhere in the same paper where we learn that the recurrence rate for superficial transitional cell cancer of the bladder is as high as 70% within five years and that 80% of patients have at least one recurrence.

First, the Diagnosis Before any treatment can be determined, it is, of course, necessary to diagnose that the patient does have bladder cancer. Usually, the process will start with a patient presenting to their GP with blood in the urine (haematuria). Sometimes, it will start with a patient presenting at A&E with pain and/or an inability to pass urine. There are other bladder infections that can cause these symptoms but, if they can be ruled out or if the patient is over 60, the next stage is to see a urologist who will arrange for a cystoscopy. In this procedure, the urologist will pass, through the urethra and into the bladder, a tube with a camera at one end and a means to view at the other. During the procedure, they will examine the inside of the bladder for any abnormalities and, where anything unusual is seen, might also use the device to take a small sample (biopsy) from the tissue in question. There are two types of cystoscopy. NHS Choices12 explains, “flexible cystoscopy – a thin (about the width of a pencil), bendy cystoscope is used, and you stay awake while it’s carried out: [and] rigid cystoscopy – a slightly wider cystoscope that doesn’t bend is used, and you’re either put to sleep or the lower half of your body is numbed while it’s carried out. 8 |WWW.HOSPITALREPORTS.EU

Flexible cystoscopies tend to be done if the reason for the procedure is just to look inside your bladder. A rigid cystoscopy may be done if you need treatment...” Just that description of the procedure suggests the challenges to be faced when designing and making a cystoscope. The device must be as slim as possible and, for a flexible cystoscopy, flexible to minimise patient discomfort during insertion. However, it must also include a camera (best quality possible to be sure that any abnormality is seen), a light source (again, the one most likely to expose all unusual areas) and the means to take a biopsy. The history of cystoscopes has already been referred to in this Report and it is the main tool for the detection and management of bladder cancer. Beyond the detection and diagnosis stage, a cystoscope might also be used by the surgeon removing the tumour and the quality of the device will play an important role in ensuring that every part of the tumour, right to the visible margin, is removed. The more of the visible margin that can be identified, the better the outcome and prognosis will be for the patient. Also, because bladder cancer has such a high recurrence rate, there will need to be cystoscopies carried out as part of the aftercare programme.

Treatment for Bladder Cancer NHS Choices13 explains that “The treatment options for bladder cancer largely depend on how advanced the cancer is. Treatments usually differ between early stage, non-muscleinvasive bladder cancer and more advanced muscle-invasive bladder cancer.” BUPA14 adds to that distinction with, “… how much of a risk it is to your health.” Most of those treatments, with the possible exception of a complete bladder removal, cystectomy, will require a cystoscopy at most follow up stages to check that all continues to be well and, if not, to detect any changes. However, as recently as 2015, NICE (National Institute for Health and Care Excellence)15 was expressing concerns about


SPECIAL REPORT: DIAGNOSING BLADDER CANCER DURING CYSTOSCOPY

INCREASE DETECTION, REDUCE RECURRENCE

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the treatment of bladder cancer, “There is thought to be considerable variation across the NHS in the diagnosis and management of bladder cancer and the provision of care to people who have it. There is evidence that the patient experience for people with bladder cancer is worse than that for people with other cancers.”

Time and Cost Time is always of the essence when dealing with cancer. With bladder cancer, that truism takes on even more significance if one factors in what has been already mentioned, that it is the most likely cancer to recur. But, it’s why it recurs that concerns us. “bladder cancer recurrence occurs via four mechanisms – incomplete resection, tumour cell re-implantation, growth of microscopic tumours, and new tumour formation. The first two mechanisms are influenced by clinicians before and immediately after resection…” that is the view in NCBI ‘Mechanisms of recurrence of Ta/ T1 bladder cancer’16 and this is where the quality of cystoscopy can make the difference. The paper

continues, “In short, the more of the tumour that is detected with the first cystoscopy and the more that is removed during the subsequent operation, the less likely the cancer is to recur. How does this affect time? The longer that cancer cells are free to grow, the more dangerous they become so a fuller detection will curtail that time to grow. Cost is similarly a function of the efficiency of the processes utilised and the tools used to carry them out. NHS figures for the cost of cystoscopy are not available but, according to Private Healthcare UK17, the private health sector charges for a cystoscopy vary between £700 and £4,700. However, the more telling statement on cost comes from the Health Economics Research Unit at University of Aberdeen18, which, having set out the costs of different cystoscopy types, concludes, “Which strategy is most cost-effective depends however on how much society would be willing to pay to obtain an additional life year [for the patient].”

There is thought to be considerable variation across

28% Visualises 28% more carcinoma in situ Source: http://www.ncbi.nlm.nih.gov/pubmed/23113702 © 2012 The Japanese Urological Association, International Journal of Urology (2013) 20, 602-609

the NHS in the diagnosis and management of bladder cancer and the provision of care to people who have it. There is evidence that the patient

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experience for people with bladder cancer is

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worse than that for people with other cancers

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SPECIAL REPORT: DIAGNOSING BLADDER CANCER DURING CYSTOSCOPY

The Quality of Light Peter Dunwell, Medical Correspondent In a process where detection is a key requirement at every stage, the ability to see what is happening is of paramount importance

The demands on service provision have led to an increasing number of check flexible cystoscopies being performed by urology nurse specialists as opposed to doctors

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H

EALTHCARE PROFESSIONALS are constantly faced with the need to meet infinite demands with finite resources. So, they must continually seek better ways to utilise the resources available to them. The use of cystoscopy in the detection and treatment of bladder cancer is no exception to that reality.

Improving Resource Usage and Speeding the Process with Best Practice Guidelines The International Journal of Urological Nursing19 suggests, “The demands on service provision have led to an increasing number of check flexible cystoscopies being performed by urology nurse specialists as opposed to doctors.” And, in case anyone might think that could lead to a reduction in quality, the statistics used in the article lead to the conclusion, “This study provides evidence that nurse-led check flexible cystoscopy sessions are comparable in quality to doctor-led sessions and supports the use of these services. This has clear implications on the delivery of a cost-effective service to meet current financial demands.” One factor in enabling such a change will be the development of more user-friendly cystoscopes with the capability to share an image quickly with a specialist if that is needed. As well as improving resource utilisation, steps to make cystoscopes that can be used by a greater range of clinicians will also have the effect of speeding the process and getting results faster for patients – less worry and the likelihood that treatment will be more effective because it will be started earlier. Reflecting this change in practice, towards more nurses performing more complex procedures, the British Association of Urological Nurses (BAUN) and The British Association of Urological Surgeons (BAUS) have jointly developed an updated guideline20. However, saying that a process should speed up is one thing; the Pan Birmingham NHS Cancer Network ‘Guidelines for the Management of bladder cancer’21 go further in setting down times within which each stage of the process should be completed, starting with, “The most common

presentation is haematuria, which should be referred as a 2 week wait. Local units should offer a haematuria clinic appointment to these patients, which should include an immediate flexible cystoscopy.”

The Light Used in Cystoscopy NICE (National Institute for Health and Care Excellence)22 adds another factor into the discussion, “The light source routinely used during the procedure produces white light. Bladder cancer is occasionally missed during cystoscopy. Therefore, other technologies have been proposed to try to improve the accuracy of cystoscopy. Two new technologies to enhance the accuracy of cystoscopy are photodynamic diagnosis and narrow band imaging [NBI]. Both technologies aim to make visual assessment of the bladder more accurate… Narrow band imaging uses a processor to filter out all but the blue and green light wavelengths. This has the effect of sharpening the contrast between normal tissue and bladder cancer. It does not require any prior preparation such as a photosensitiser.” That last part is important in the efficiency context because photodynamic diagnosis requires the instillation of a photosensitiser compound into the bladder shortly before cystoscopy whereas narrow band imaging does not. The conclusion was that narrow band imaging showed consistently better results at both the detection and the resection stages which resulted in a lower rate of recurrence – see the paper (page 78 onwards) for full results. Given that the whole process takes place within a patient’s bladder but has to be read by a clinician whose view is only as good as the image transmitted to them, the quality of the light used in a cystoscope is very important. Until fairly recent times, cystoscopies were carried out using white light. However, whatever is done to improve white light, its brightness might change but what it can reveal remains the same. So, development has gone down the route of identifying light sources that would not simply reveal the same but would instead reveal more detail and, importantly,


SPECIAL REPORT: DIAGNOSING BLADDER CANCER DURING CYSTOSCOPY

INCREASE DETECTION, REDUCE RECURRENCE COPYRIGHT BY OLYMPUS EUROPA SE & CO. KG

more of any lesions or tumours. As the Central European Journal of Urology explains in the abstract of ‘Review of current optical diagnostic techniques for non-muscle-invasive bladder cancer’23, “Macroscopic techniques, such as narrow band imaging, are similar to white light cystoscopy; however, they help visualize even very minute lesions in the bladder mucosa by means of contrast enhancement.” The paper continues to explain its reservation about white light cystoscopy (WLC), “Firstly, WLC does not allow for cancer grading or determination of infiltration status. Secondly, while sufficient in identifying papillary lesions of over 0.5 cm in diameter, WLC can sometimes be inadequate in identifying small or flat solid tumors, including carcinomas in situ (Cis), whose detection rates in WLC do not exceed 58–68%. The high risk of Cis oversight may lead to incorrect, conservative treatment rather than a radical approach; this may ultimately lead to progression of BC [bladder cancer] into incurable metastatic disease.”

Narrow Band Imaging We’ve already mentioned narrow band imaging in several contexts in this Report. In a comparison of white light and narrow band imaging in cystoscopy for the Cochrane Library24, the

conclusion was that, “Narrow-band imaging enhances visibility of bladder tumors over conventional white-light cystoscopy… [and] narrow-band cystoscopy improves surgical removal of bladder tumors, which reduces the frequency of early and later tumor recurrences.” For a patient with the most recurring cancer, that matters. A similar conclusion was drawn by University of Birmingham25, “Research into bladder tumour surgery has found that using narrow band imaging can significantly reduce the risk of disease recurrence… Only 5.6% of low-risk patients in the narrow band imaging (NBI) facilitated surgery group experienced a recurrence of bladder tumours in the 12 months following surgery, compared to 27.3% in those who underwent conventional TURBT (trans urethral resection of bladder tumours) surgery.” That’s the clinical case, following which the cost-effectiveness should be clear. Better detection rates mean less repeat cystoscopies and earlier surgeries which, if they are also more likely to remove all of the affected tissue, will lead to less recurrence of the condition. At each stage of the process, a more effective outcome will save the cost of future avoidable treatments. Good for the clinician, good for the budget and, most of all, good for the patient.

17% Reduces risk of recurrence to 17% at one year Source: http://www.ncbi.nlm.nih.gov/pubmed/23113702 © 2012 The Japanese Urological Association, International Journal of Urology (2013) 20, 602-609

Given that the whole process takes place within a patient’s bladder but has to be read

Learn more by visiting our online NBI Portal.

by a clinician whose view is only as good as

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SPECIAL REPORT: DIAGNOSING BLADDER CANCER DURING CYSTOSCOPY

Weighing Up the Factors and Making a Decision John Hancock, Editor Choosing a cystoscope today and what the future might hold for cystoscopy and bladder cancer patients

it is likely that the whole process will continue to improve so that patients don’t need to wait so long for each stage or for each result, which will further improve the prognosis

F

OR ALL of the clinical benefits that can be attributed to one device or another, at some point, the clinicians and managers in a healthcare unit will have to choose the device and system that best suits their needs. This is not going to be a definitive or prescriptive list of things to consider because each professional clinician will need to bring their own circumstance, priorities and experience to bear; but hopefully, this article will help to identify some areas deserving of inclusion in any choice.

Key Factors in Choosing Bladder Cancer Diagnostic Tools The first priority every time has to be the patient and the fact is that bladder cancer patients have not always been the best served in any healthcare system. That’s not good: as IOS Press reported in ‘Defining Priorities to Improve Patient Experience in Non-Muscle Invasive bladder cancer’26, “Patient experience is increasingly being recognized as an important metric” in any decisions about what to use and how to use it. There’s a reason for that, as the article continues, “Poor care satisfaction and experiences have been associated with outcomes such as lower health-related quality of life, mental well-being, and decreased adherence to care…” Unfortunately, one finding of the survey cited in the article, “found that bladder cancer patients have among the lowest levels of satisfaction with care when compared to other urologic cancer sites and cancer generally…” A similar picture emerges from The British Journal of Cancer’s ‘Understanding missed opportunities for more timely diagnosis of cancer in symptomatic patients after presentation’27: the title sets the tone and the article continues the theme, “A large body of evidence based on analysis of the clinical details of cohorts of cancer patients suggests that ‘missed opportunities’ occur in substantial proportions of patients.”

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Without wishing to labour the point, one overriding concern in any choice must be ‘will whatever we purchase help to improve our bladder cancer patients’ experience?’ Looking back over this paper, it is possible to identify and bring together a number of factors for consideration in any purchasing decision of a cystoscopy system.

Rate of detection We have seen how important it is that detection takes place as early as possible and as completely as possible in order to offer a patient the best chance of treatment that will improve their condition now and with the lowest likelihood of a recurrence. In a similar vein, a tool that can offer the same benefits to the operating surgeon to remove more or all of the affected tissue will also minimise the chances of a recurrence. The benefits for the patient are obvious but, also, patients who have less need for healthcare services cost the system less.

Patient comfort As we’ve seen, the cystoscopy process is hardly a naturally comfortable thing. Added to the actual insertion through the urethra which can be accompanied by a localised anaesthetic, it is likely that a patient who is unfamiliar with the procedure will also feel some stress. Handling that is part of the training for a urologist, but it will also be the case that the more user-friendly and patient-friendly the device, the sooner the patient will relax.

Likelihood of recurrence This has already been thoroughly covered but bears brief repetition when we’re considering the cancer with the highest recurrence rate. Reduced likelihood of recurrence is good for all parties: the clinician, the healthcare system and, most of all, the patient.


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Ease of use Although this crosses with patient comfort, it is also important that any tool does not require so much of the user’s attention that they take focus away from the task for which the tool is intended. A cystoscope is no different and so one that is easy to use is likely to let the clinician focus all their professional attention on the examination.

Use of tool for training This is really important in a healthcare system which, as previously stated, needs to meet infinite demand from finite resources. The faster and better clinicians are trained into a procedure such as cystoscopy, the sooner they can be added to the roster for conducting those procedures. One thing that will help is the ability for a teacher and students to share an examination in real time and/ or to be able to record an examination highlighting a specific point to be used in future training. There are other factors to consider such as whether the new system is compatible with systems already in use and is able to connect with them for speed of communication. And, of course, no consideration of choice can ever ignore cost. However, cost consideration should not ignore the longer term financial benefits for the healthcare system of a more effective solution.

The Future Outlook for Cystoscopy Cystoscopy has come a long way in a little over two centuries according to the British Association of Urological Surgeons’ Virtual Museum28. Interestingly, the museum’s exhibit on cystoscopy emphasises the importance of light in the procedure and many of the articles about improvements in the cystoscope talk about the different types of light employed, from white light through blue light (including photodynamic) and narrow band light. The development of fibreoptic transmission enabled the device to become more comfortable and improved the quality of what the examiner could see. But, given that bladder cancer is most prevalent in the over 60s and that there is an aging population, what does the future hold? The likelihood is that there will continue to be developments of the cystoscope itself with softer more flexible materials and higher capacity components such as the fibreoptics, the camera, the viewing screen and the software. With HD (high definition) images already available, it can be assumed that the super HD now beginning to appear in sport television, will soon be available for medical purposes. Also, IT related, it is likely that the whole process will continue to improve so that patients don’t need to wait so long for each stage or for each result, which will further improve the prognosis.

17% Detects bladder cancer in 17% additional patients Source: http://www.ncbi.nlm.nih.gov/pubmed/23113702 © 2012 The Japanese Urological Association, International Journal of Urology (2013) 20, 602-609

Learn more by visiting our online NBI Portal. www.nbi-portal.eu/en/uro

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References: 1

Pub Med www.ncbi.nlm.nih.gov/pubmed/23113702

2

Action bladder cancer UK actionbladdercanceruk.org/the-facts-about-bladder-cancer/

Science Direct www.sciencedirect.com/science/article/pii/S0302283815010052 4 cancer Research UK www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/bladder-cancer/incidence 3

5

Patient patient. https://patient.info/doctor/bladder-cancer-pro

6

NHS Choices www.nhs.uk/conditions/bladder-cancer/causes/

7

cancer Research UK www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/bladder-cancer/risk-factors

8

NHS Choices www.nhs.uk/conditions/bladder-cancer/symptoms/

9

National cancer Intelligence Network file: http://www.ncin.org.uk/view?rid=1001

10

cancer Research UK www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/bladder-cancer/survival

11

Patient patient. https://patient.info/doctor/bladder-cancer-pro

12

NHS Choices www.nhs.uk/conditions/Cystoscopy/

13

NHS Choices www.nhs.uk/conditions/bladder-cancer/treatment/

14

BUPA www.bupa.co.uk/health-information/directory/b/bladder-cancer

15

NICE www.nice.org.uk/guidance/ng2/resources/bladder-cancer-diagnosis-and-management-of-bladder-cancer-51036766405

16

NCBI www.ncbi.nlm.nih.gov/pmc/articles/PMC3182798/

17

Private Healthcare UK www.privatehealth.co.uk/conditions-and-treatments/bladder-examination-by-camera-cystoscopy/costs/

18

Health Economics Research Unit, University of Aberdeen 2010 www.abdn.ac.uk/heru/documents/BP/Briefing_paper_34_2010_April.pdf

19

The International Journal of Urological Nursing onlinelibrary.wiley.com/doi/pdf/10.1111/ijun.12077

British Association of Urological Nurses, ‘Flexible Cystoscopy Training and Assessment Guideline’ http://www.baun.co.uk/files/6515/1153/9224/A45913-Flexi-Cystoscopy-Guidelines.pdf 20

Pan Birmingham NHS cancer Network, ‘Guidelines for the Management of bladder cancer’ www.uhb.nhs.uk/Downloads/pdf/cancerPbbladdercancer.pdf 21

22

NICE www.nice.org.uk/guidance/ng2/evidence/full-guideline-3744112

23

Cochrane Library cochranelibrary-wiley.com/o/cochrane/clcentral/articles/458/CN-01052458/frame.html

University of Birmingham, ‘Narrow band imaging can reduce recurrence of bladder tumours’ www.birmingham.ac.uk/news/latest/2016/04/Narrow-band-imaging-can-reduce-recurrence-of-bladder-tumours.aspx 24

University of Birmingham, ‘Narrow band imaging can reduce recurrence of bladder tumours’ www.birmingham.ac.uk/news/latest/2016/04/Narrow-band-imaging-can-reduce-recurrence-of-bladder-tumours.aspx 25

26

IOS Press content.iospress.com/articles/bladder-cancer/blc170138

27

British Journal of cancer www.nature.com/articles/bjc201547

28

The British Association of urological Surgeons Virtual Museum www.baus.org.uk/museum/101/cystoscopy

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INCREASE DETECTION, REDUCE RECURRENCE

28%

Visualises 28% more carcinoma in situ

17%

Detects bladder cancer in 17% additional patients

17%

Reduces risk of recurrence to 17% at one year Compared to WLI Source: http://www.ncbi.nlm.nih.gov/pubmed/23113702 © 2012 The Japanese Urological Association, International Journal of Urology (2013) 20, 602-609

NARROW BAND IMAGING For Non-Muscular Invasive Bladder Cancer Learn more by visiting our online NBI Portal. www.nbi-portal.eu/en/uro

Excellent view of mucosal and vessel structures even with white light.

KeyMed House, Stock Road, Southend-on-Sea, Essex, SS2 5QH, UK +44(0)1702 616333 | www.olympus.co.uk

NBI filters the white light and improves contrast of mucosal and vessel structures.

Olympus Medical UKIE

OlympusMedicalEurope

@OlympusMedUKIE

Olympus Med UKIE


SPECIAL REPORT: DIAGNOSING BLADDER CANCER DURING CYSTOSCOPY

Notes:

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Hospital Reports Europe – Diagnosing Bladder Cancer During Cystoscopy – Olympus UK  

Hospital Reports Europe – Diagnosing Bladder Cancer During Cystoscopy – Olympus UK

Hospital Reports Europe – Diagnosing Bladder Cancer During Cystoscopy – Olympus UK  

Hospital Reports Europe – Diagnosing Bladder Cancer During Cystoscopy – Olympus UK