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Mr Param Mariappan FRCS(Urol), PhD

Consultant Urological Surgeon, Western General Hospital, Edinburgh

As healthcare battles to be more efficient and more effective, investing upstream in photodynamic diagnostics could help improve patient outcomes.

When it comes to treating bladder cancer, time is of the essence. But the COVID-19 pandemic has led to delays at every stage of the patient journey.

“Last March, we were doing more new non-muscle invasive resections, now we’re seeing far more invasive tumours at first presentation,” explains Mr Param Mariappan, Consultant Urological Surgeon at Western General Hospital in Edinburgh.

Mr Mariappan’s observations are backed up by the stats. As of August 2020, the proportion of patients in England waiting at least six weeks for a cystoscopy was 50.2% in comparison to 9% in August 2019 according to NHS statistics.

As Mr Mariappan continues, “Unfortunately, with bladder cancer once it’s more advanced the prospect of cure gets less.”

Early diagnosis is crucial

Diagnosis is key to ensuring patients are put on the correct treatment pathway. Following a cystoscopy and a scan of the urinary tract, patients suspected of having bladder cancer should be offered a transurethral resection of bladder tumour (TURBT). It’s a crucial investigation where abnormal tissue samples are removed and tested, followed by chemotherapy (into the bladder) in appropriate patients.

“A good, effective operation at the outset can reduce the chance of future recurrence and get necessary staging information to find out if the patient has a more invasive condition,” he confirms.

However, errors can and do occur when using standard white light cystoscopy for the initial diagnosis, and surveillance of non-muscle invasive bladder cancer. As Mr Mariappan observes, “This is where photodynamic diagnosis has a big role to play.”

Utilising photodynamic diagnostics

Photodynamic diagnosis (PDD) involves using a catheter to squirt a non-irritant chemical into the bladder prior to TURBT. The chemical induces fluorescence in potentially malignant tissue, which can be seen using a blue light.

It has proven to be particularly effective in identifying invisible abnormalities such as papillary lesions and carcinoma in situ. “Initial studies suggest that the pick-up of tumours is about 20% better,” confirms Mr Mariappan.

At the moment, PDD is largely used in new bladder cancer patients in select hospitals, but Mr Mariappan would like to see it as standard practice, especially for training. As hospitals face increasing pressures of COVID-19 and a backlog of operations, the need to “invest upstream” has never been greater.

“We need to be both effective and efficient,” continues Mr Mariappan. “If you don’t get it right the first time, patients will more likely have to come back, so adjuncts, like PDD, can help reduce repeat operations and recurrence of tumours.”

However, like so many things, cost is the deciding factor. PDD comes at a price and the NHS is currently undertaking trials to establish the cost-effectiveness of the intervention. As Mr Mariappan says, “We’re waiting for the results with bated-breath!”

©Image provided by KARL STORZ Endoscopy (UK) Ltd
The same bladder cancer tumour viewed with white light cystoscopy (left) and KARL STORZ PDD Blue Light Cystoscopy (right)

Greater consistency is needed

While PDD could lead to better patient care and reduce the need for repeat resections, Mr Mariappan believes there are other considerations. “Bladder cancer has been viewed as the ‘Cinderella cancer,’ for too long,” he explains.

In 2002, the European Organisation for Research and Treatment of Cancer published a paper that showed the percentage of patients with a recurrence in the bladder varied substantially between institutions.

The only reasonable suggestion was that the quality of the TURBT performed by surgeons differed considerably. The procedure has traditionally been left to junior members of staff to perform, sometimes without adequate supervision and without a standardised approach, which Mr Mariappan believes to be a contributing factor to the variable outcomes.

“For many, TURBT is not seen as a ‘sexy operation’. It is the unintentional victim of the lure of other surgery using more technical, expensive equipment,” he says. Mr Mariappan believes that more needs to be done to inspire interest in the field and introduce greater consistency in the way TURBT is conducted.

This needs to start from day one – and that means doing everything we can to quickly and accurately diagnose and stage cancer. PDD could have a significant role to play in the process.

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