Transcript: What is the Best “Light” to Detect Bladder Cancer When Getting a Cystoscopy? with Dr. Yair Lotan

August 10, 2021

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Voice over:	This is Bladder Cancer Matters. The podcast for bladder cancer patients, caregivers, advocates and medical and research professionals. It’s brought to you by the Bladder Cancer Advocacy Network, otherwise known as BCAN. BCAN works to increase public awareness about bladder cancer, advances bladder cancer research, and provides educational and support services for bladder cancer patients and their loved ones. To learn more, please visit bcan.org.
Rick Bangs:	Hi, I’m Rick Bangs, the host of Bladder Cancer Matters, a podcast for, by, and about the bladder cancer community. I’m also a survivor of muscle invasive bladder cancer, the proud owner of a 2006 model year neobladder, and a patient advocate supporting cancer research at the Bladder Cancer Advocacy Network, or as many call it, BCAN, producers of this podcast. This podcast is sponsored by Merck.
	I’m excited to have as my guest today Dr. Yair Lotan, Professor of Urology, Chief of Urologic Oncology at UT Southwestern Medical Center. He is also the Medical Director of the Urology Clinic at UT Southwestern and Parkland Health and Hospital System. In addition, he is on the BCAN’s Scientific Advisory Board. Dr. Lotan has a consulting advisory relationship with Photocure, US distributor for blue light cystoscopy equipment in the United States. Dr. Lotan, I’m so pleased to have you here today to talk about a very common bladder cancer procedure, the cystoscopy.
Dr. Yair Lotan:	Thank you very much. It’s a pleasure speaking with you.
Rick Bangs:	A recent podcast focused on the challenges of how far a patient’s bladder cancer has progressed. And we talked in that podcast a little about the cystoscopy. Today, I want to focus in more detail on the cystoscopy and some of the nuances of that particular procedure. So let’s start by setting the stage. The cystoscopy is an important tool in the urologist diagnostic arsenal. So when do you use a cystoscopy?
Dr. Yair Lotan:	Good. So as you mentioned, cystoscopy is the basic tool. And in fact, it is the main tool that we use to evaluate patients who have blood in the urine. And that is the most common way that bladder cancer is diagnosed. The typical complaint is that I have blood in the urine usually it’s painless as opposed to in patients who have a bladder infection where they might have some bladder pain. And the evaluation includes typically evaluation with imaging either CT scan or ultrasound of the kidneys and a cystoscopy which is a visual inspection of the urethra and the bladder. And that is how we look around and make sure that there is or is not a bladder tumor.
	And so it’s really the first step for us to evaluate patients to find out if they even have bladder cancer. Unfortunately, imaging is not very useful in looking for tumors in hollow organs, and that is why people have to do colonoscopy to evaluate the lining of the colon and why we have to do cystoscopy to evaluate the lining of the bladder.
	Primarily if you have a very large tumor or you have growth through the wall of the bladder, you can see it on imaging, but many bladder tumors are smaller. And when the bladder is collapsed, you cannot see any solid areas within the bladder. And so when we look with a fiber optic camera with a light source which is a cystoscope, we can see the lining of the bladder very clearly. We fill the bladder with some fluid. It distends it so we can see all the surfaces. And so that is the initial tool that we use for diagnosis.
	As most patients with bladder cancer are aware in order to make an initial diagnosis, we do need tissue. And the next step is to go to the operating room. And under anesthesia, we use a cystoscope to evaluate the bladder again. And this time we have several tools that we use to scrape the bladder or biopsy the tumor in order to assess, first of all, that we have a correct diagnosis and then also the stage and the grade of the tumor itself.
Rick Bangs:	Okay. So you talked a little bit about the limitations of imaging. And I know some patients are hoping that at some point that that would be a replacement for the cystoscopy, but there’s also urine samples and blood. And at this point, those things are really not as good or even close to providing you the information you would need that you would get from a cystoscopy. Is that right?
Dr. Yair Lotan:	So you touched on several important issues. First of all, if you have blood in the urine, you need to have certainty about the presence or absence of bladder cancer because if we look in your bladder and we do not see a tumor, you likely will not come back into the urologist again for further evaluation. This is quite different than a patient with known bladder cancer where we will periodically look in the bladder as part of a surveillance protocol to evaluate for any new tumors.
	You broke down several different potential avenues of detecting cancer less invasively than looking in the bladder. I’ll address the easy one which is blood. We do not have good tumor markers in the blood for bladder cancer detection. There are some tools that are being evaluated for future surveillance, looking at circulating tumor cells or DNA in patients with more advanced disease. However, these have not been validated and are not commercially recommended quite yet.
	As far as the urine, there are several available tests. Some of them are FDA approved. Some of them are commercially available. And some such as just looking in the urine for any suspicious cells which is called cytology are commonly utilized. However, cytology suffers from some drawbacks in terms of a low sensitivity for low grade cancer. And even for high grade cancer does not detect anywhere from 30% to 50% of tumors. And so we do not use it to replace cystoscopy.
	However, because we know that cystoscopy with white light which is the most commonly used form of cystoscopy can miss small tumors and flat tumors such as carcinoma in situ, we do use a urine wash with cytology as an adjunct measure to try to catch any cancers that were missed. And we’re going to talk a little bit more I’m sure about enhanced cystoscopy later, but most patients still undergo white light cystoscopy and cytology is used in addition cytology use in addition to cystoscopy, not to replace it.
	As far as urine markers are concerned, there are several different things you can look in the urine in patients with bladder cancer. You can look at small molecules like DNA, protein, RNA. And there are a variety of tests that have evaluated these particular modalities. The problem with some of these markers is that they can also miss some high-grade cancers and they also have the potential for false positive results. They are being used in various different clinical scenarios, but not yet to replace cystoscopy.
Rick Bangs:	Yeah, so it sounds like the cystoscopy is the best alternative we have here. And at some point, some of these other things may come into play, but this is clearly the best we have. And so you talked a little bit about different kinds of light, but there’s also different types of cystoscopies in terms of rigid versus flexible. So could you talk a little bit about what those are?
Dr. Yair Lotan:	Sure. The most common cystoscope used in the clinic is a flexible cystoscope. The cystoscope is basically made of a material that can bend. It’s typically narrower than a rigid scope, even though there are some small rigid scopes that we use. But for the most part, the flexible scope in the office is a size of a typical catheter that we put in the bladder. And as I mentioned, it can bend on itself so you can almost look back at yourself when you’re in the bladder. It is most commonly used in patients who are awake because the rigid scopes are much less comfortable to insert. There are some urologists that use rigid scopes in women because the urethra is short, but I suspect most women would prefer to have a flexible scope. And I routinely use flexible scopes in men and women.
	A rigid scope would be quite uncomfortable in a patient who is awake, especially the larger caliber. And so most of the time, we just use it in the operating room setting when the patient is under anesthesia and would not perceive pain from use of the more rigid scope. We use a more rigid scope for a variety of reasons. First of all, the larger diameter of the sheath allows you to have better irrigation in the bladder. And you can have both inflow and outflow channels while the flexible scope is much more narrow. And so the working channel is small and you can only have fluid go in, but you can not have it go out, which means you can only have so much fluid go in before the bladder becomes distended and uncomfortable.
	In the operating room, you want to be able to fill and empty the bladder. It allows you to have sometimes better visualization than also if you’re scraping a tumor, resecting it, you might have some bleeding. And so the continuous flow will facilitate visualization. Generally speaking, the rigid scopes come in various sizes, and some of them are a little bit more narrow if you just want to have a look, but you also have larger caliber ones if you do need to do a biopsy or a resection.
Rick Bangs:	So when I have a TURBT procedure, are you using a rigid cystoscope as part of that? And is there like some little scalpel as part of the cystoscope?
Dr. Yair Lotan:	No, you’re exactly right. There is a rigid scope. For TURBT, it’s called the resectoscope. It has several different… It has an outer sheath and then an inner working channel so that you can put in a tool that looks like a C-shape that is an electric cautery device that you can use to cut part of the bladder wall and the tumor out. And then because there’s a sheath, you can pull the fragments out through the sheath and then reinsert your working device if you need to cauterize or go in and out several times if you had to empty the bladder or remove parts of the tumor. And so every time you have surgery in the operating room, you almost exclusively will use rigid scopes.
Rick Bangs:	And you’re going in and you take those samples and then you take the device out and remove the sample and then you put it back in, right? That’s what it sounds like.
Dr. Yair Lotan:	But you leave the outer sheath in the bladder at all times.
Rick Bangs:	Okay. Okay.
Dr. Yair Lotan:	So the outer sheath is the largest diameter and it’s the one that’s connected to the fluid. So you can keep the fluid running and irrigate out the bladder as you’re working. And then when you want to remove specimens, you don’t have to come in and out of the urethra every time you leave your outer sheath all the way in the bladder, and you can come in and out of the bladder without necessarily going through the urethra.
Rick Bangs:	Okay. That makes sense. All right. So I know because I talked to a fair number of patients and I’m sure you hear about it all the time, but patients do complain about discomfort even with that flexible cystoscopy. So what are some things that can be done to minimize the discomfort? Are there things the patient can do or the clinician or the combination?
Dr. Yair Lotan:	Right. So first of all, there are some things you can do. They work for some patients and not others. And in fact, there’s several studies that have been performed to try to evaluate different types of therapies, but unfortunately most of them have not been done in a rigorous fashion. The most common tool that we use, that I use routinely is Lidocaine jelly. And you can instill Lidocaine jelly and let it dwell in the urethra for five to 10 minutes. And that seems to help with some of the local discomfort in the urethra at the time of the procedure.
	Other things have less evidence. Some people like to watch the monitor with a urologist narrating the procedure so they can see what’s going on and that services a way to focus on something else other than the procedure by looking in. Some patients like to wear headphones and listen to music and distract themselves and only talk to you about the procedure after you’re done.
	One of the things that I think is helpful is, if a patient tries to relax during the procedure, it sounds like a challenge because how can you relax when somebody’s putting a tool in their urethra? But you have a sphincter that keeps you from leaking urine. And the tighter you are wound up and tightening your sphincter, we have to go through that muscle in order to get into your bladder. And so often I’ll tell my patients to pretend like they’re urinating when I’m trying to go through the sphincter so they can try to relax that sphincter so that I’m not pushing against this muscle. There are not very many things the patient can do and even telling a patient to relax while you’re doing a procedure on them is not always so useful. But it does seem like over time patients tend to tolerate the procedure better. And that just speaks more to the human spirit than it does to the urologist skill.
Rick Bangs:	Are there patients for whom it would make sense to ask for something like Valium or some sort of, tranquilizer’s the term that I would think of that might help them or is that an unusual thing?
Dr. Yair Lotan:	There’s a difference between what a urologist consider is a minor procedure and there’s a joke that says a minor procedure is something that’s done on somebody else.
Rick Bangs:	Yeah, agreed.
Dr. Yair Lotan:	And so I never really refuse a patient who says, “I’m not going to be able to do this procedure unless you give me something.” I will prescribe them a Valium. But the vast majority of patients and I do this procedure eight to 12 times a day, and when I’m in clinic do not need it. And there’s an inconvenience with getting a Valium, you can’t drive yourself, you can’t drive home. Maybe if I’m telling you about what’s going on, you can’t remember it. And the fact is that at the end of the day, it’s a two to three minute procedure. And so I’ve had a few patients and they say… I do it and they say, “You’re not doing that again with me without some sedation.”
	If a patient asks for me to go under anesthesia, I essentially will talk them out of that idea and talk them into a Valium because I think a general anesthetic for two to three minute procedure is much more risky for you. However, I think it tends to be fairly tolerable and it’s a fairly short procedure, again, two to three minutes. And if you instill some lidocaine and proceed gently, most patients can tolerate it fine.
Rick Bangs:	Yeah, I think that was one of the things that surprised me personally. The two cystoscopies I’ve had was how short they were because you don’t know no going in unless your doctors has told you. So I think that’s an important thing to keep in mind. Okay. So let’s talk about the lighting side of the cystoscopy. So we have normal light which we might call white light, but there’s a blue light cystoscopy and something called narrow-band imaging. So can you tell us what these are and how are they different?
Dr. Yair Lotan:	Sure. So white light is essentially if you look at any light in your house unless they have like a special light bulb, most lights are white. Maybe they have a little shade of yellow, but the vast majority of lights are white. And if you look… If you have a camera with a fiber optic cable, the light is white. And so when we look in the bladder, we are shining a white light against the bladder wall which has a yellowish pale to pink coloring with some faint blood vessels. And most bladder tumors have a pale white to yellow appearance unless they’re actively bleeding, which most of them are not. And so while it’s easy to distinguish a two to three centimeter, a larger tumor, they tend to look a little bit like coral do, at least that’s the analogy I use on a stock and a little flapping, you can miss small tumors because there’s no discernible color difference between the two.
	Now, narrow-band imaging, and maybe we need to take a step back. There are a couple of companies that make scopes in the US, one is Olympus, one is STORZ, and there are several other companies, Wolf, et cetera, that maybe more common in Europe. But most Olympus’ scopes come with a button that will switch you from white light to narrow-band imaging. Narrow-band imaging is a technology that splits white light into a specific light wavelengths. These different light wavelengths are absorbed by blood vessels and penetrate just a little bit under the lining. And so they highlight the blood vessels and make them have a greenish or brown appearance.
	They do not highlight tumor specifically, but many tumors in the bladder attract blood vessels just like other tumors in the body. So they bring the blood vessels into focus and it might draw your eyes to an area with more blood vessels and then you might pick up a tumor that might be sitting there that was not so obvious with the white light. But now that you’re looking at these blood vessels more specifically, you also will catch some other areas. Now, this is a feature that comes specifically with Olympus scopes and most Olympus scopes have this feature. And like I said, you just click a button and it switches and you can click the button and switches back.
	Now, there are some studies that have shown that with narrow-band imaging, you can improve detection of bladder cancer. So it’s something that’s easy to do. And I will periodically do it, especially if the bladder has trabeculation or chronic changes or the patient’s had prior instrumentation or intravesical therapy such as BCG or chemotherapy, sometimes they’ll help me distinguish things. I don’t do it in every patient.
	It should be noted that STORZ’s scopes also come with a technology called CHROMA which is similar in technology to it. And I have a caveat as you told them I would consult for Photocure. I also have done research with STORZ’s looking at this CHROMA and it does appear to give a little bit better definition to certain tumors when you look at them in the bladder.
	Now, as far as blue light cystoscopy, it is a very different type of technology. The patient needs to come in about an hour before the procedure and have installation of a compound called Cysview, which is a protoporphyrin. And this is a chemical that is used as a building block by cell, it’s a nutrient. And it gets taken up preferentially by cancer cells. And it has a property that when you shine a blue light on it, it makes cells look pink.
	And because cancer cells take up this compound and normal cells do not, you can differentially see cancer cells because when you shine the blue light on them, they appear pink because they could be bright pink, sometimes they’re less bright. And it does have the ability to improve detection, especially of a condition called carcinoma in situ, which is notoriously difficult to find because it tends to be a flat patch. It’s sometimes can be a little reddish, but often is missed with white light cystoscopy.
	So in studies it’s been shown that about a 30% higher detection rate of carcinoma in situ, and about a 20% higher detection rate of just papillary tumors. And so it was approved in 2018 for use with flexible scopes. It’s been used for rigid scopes for more than eight years. And in fact, there are studies that show that if you use it when you resect the tumor, you’ll reduce the recurrence rate at a year compared to resecting just with white light. And in fact, our guidelines even recommend use of blue light cystoscopy. And there’ve been imaging to improve resection and detection of cancer. As far as the scopes, you can only use STORZ’s scopes in the US for this. So you do need to have specialized equipments to do blue light cystoscopy right now. And you can’t just use any scope you have for it.
Rick Bangs:	Okay. So with the blue light, I need to have this chemical in my bladder for an hour, but it sounded like with the narrow-band imaging, you’re just flipping the switch. So do I need to have anything installed in my bladder special for the narrow-band imaging? Or is it no preparation or the same preparation you would have for the white light?
Dr. Yair Lotan:	Right. There’s nothing special just beforehand. No, you don’t need anything instilled. That’s one of the nice things about that technology is that’s available essentially with most of the Olympus scopes currently.
Rick Bangs:	Okay. And if I had a blue light or narrow-band imaging, would I have it done as frequently? Would my repeats be as frequently? Or can we space things out a little bit further?
Dr. Yair Lotan:	That’s a good question and not one that’s been answered. The original studies that looked at blue light just used that as an adjunct to white light, but did not change surveillance schedules based on having a blue light and white light. In some ways I would argue that your schedule of surveillance should be based on your risk of recurrence because having a blue light will potentially improve the detection and treatment of current tumors. But in the sense when you have a recurrence, there’s two possible scenarios. Scenario one is that other areas in your bladder were affected by carcinogens, which is the most common thing. Bladder cancer is multifocal. In many cases, multiple areas will have bladder tumors arise at different time points. And so if you have a recurrence after a tumor was resected, it’s usually a different tumor than the one that was resected.
	However, there’s also a scenario where you had four or five tumors and somebody may only have seen three because two of them were smaller, they missed them, and those tumors will grow over time and you will see them down the road. And so three months or six months later, you’re seeing a tumor that was there for three or six months just it was very smaller or was missed.
	So those are the two scenarios. So if you use enhanced cystoscopy and you find those other two tumors, in the first place that they won’t be there in the future. But if you are going to develop tumors in different parts of the bladder that were not there, then those tumors will still arise. Now, we don’t have a good way of knowing when we initially resect you, whether or not you have tumors that are going to show up in three to six months.
	We know that patients who are low-risk of small, low-grade tumors that are isolated are less likely to have multiple recurrences. On the other hand, patients who have multiple tumors initially or who have multiple recurrences are more likely to have tumors in the future. So we usually plan on how frequently we’ll look in your bladder based on the initial characteristics of your cancer or the behavior of your cancer. So at this time, use of enhanced cystoscopy has not changed how frequently we will look in your bladder.
Rick Bangs:	So do you really just need a lot of training to use these newer options?
Dr. Yair Lotan:	So generally speaking, the cystoscopy is very similar procedure. The scopes are identical. You do not need training using the system scope itself. The area that is helpful to get experiences to be able to discern what you’re looking at and get experience with what is considered a suspicious lesion versus not. Many residents who are currently getting training would have exposure to these at centers that are commonly using them. But some of the technology like flexible blue light cystoscopy was only approved three years ago. So urologists who trained prior to that would not have much experience.
	The good news is that there are a lot of videos out and there are reference centers. So I can plug the fact that we’re a reference center for blue light cystoscopy. And so we teach urologists who are interested in the approach. I think the key is that you do need some experience to determine what does represent a suspicious lesion with blue light, not every pink lesion turns out to be cancer. And we know that the false positive rate is about 9%, which means that you see an area that looks pink and you biopsy it and turns out to be inflammation. Or some area that’s not cancer, that to me seems like a good trade-off when you have an opportunity to detect about 30% more carcinoma in situ are 20% more cancers, but it is a trade-off. For urologists, I think it does help to see some of these procedures get a feel for what suspicious areas look like and how to use the technology. Yeah, and there are various different opportunities to be able to do that.
Rick Bangs:	So given the differences between these types of cystoscopy, would my ability to participate in a clinical trial change if I’ve had an enhanced cystoscopy versus the standard cystoscopy?
Dr. Yair Lotan:	So generally speaking, eligibility for clinical trials is based on the pathology report. What type of cancer, stage, grade, have you had prior BCG or not or other therapies? I’m on steering committee for several different trials. And currently use of blue light cystoscopy is not a criteria either for or against an inclusion in a trial and it does not exclude you from a trial.
	I would say that use of blue light does sometimes reveal scenarios where you might be eligible or might not be eligible for a trial because for example, if you had a trial for patients who have BCG unresponsive disease, in other words, they have a recurrence despite BCG, if you had a lesion, a carcinoma in situ that was missed with white light while you’re getting BCG, you and your urologist may both think you’re having a good response to BCG. And of course, you would not go on a trial on the assumption that you’re having a good response.
	On the other hand, if a blue light cystoscopy finds that you have carcinoma in situ, that means now you have BCG unresponsive disease and you would be eligible for a trial that you might otherwise not enroll in. On the other hand, you could be in a trial for patients with BCG unresponsive disease and the white light looks good and you think that the therapeutic agent is working, but you have blue light cystoscopy, and you find that you have a recurrence that is detected by blue light, not white light. Now you find out that you have to leave the trial because you’re really not responding to the therapy. From my perspective, I think it’s a good to know the truth because why would you want to be on an agent that’s not working for you? On the other hand, that is a way that blue light could impact enrollment in trials, either positively or negatively.
Rick Bangs:	And how common are these enhanced cystoscopies? Do a lot of centers offer these? Are they typically in urban centers or in the community? Is it easy or hard to go to a clinic that has enhanced cystoscopy?
Dr. Yair Lotan:	Unfortunately it’s not that easy to find centers with certain types of enhanced cystoscopy. Now, most urologists would have an Olympus’ scope around and could do narrow-band imaging. And in that sense, there is plenty of opportunity to get narrow-band imaging if a urologist felt that it was valuable to add that at the time of white light cystoscopy. And again, it doesn’t require any special prep. Just requires the scope of a button that allows you to convert to narrow-band imaging.
	Blue light cystoscopy requires specialized equipment, and some hospitals have it and some hospitals do not. Similarly, the flexible blue light requires specialized flexible scopes. And currently, I think it’s only available in maybe 20, 25 centers in the entire United States, even though it’s been approved for more than three years. So I believe that we’re the only ones in North Texas who have it. And even though other urologists could acquire it, it’s a choice that they make whether or not to get it. As far as hospitals are concerned, many of the academic centers have it in their hospital, not necessarily in their outpatient clinic. But again, I would say that probably a minority of resections in the US are currently done with enhanced cystoscopy with blue light.
Rick Bangs:	So for the most part, am I going to a hospital setting if this equipment is being used as opposed to a physician’s office?
Dr. Yair Lotan:	It’s definitely more common in the hospital setting than in a physician’s office. I would just say it’s still not common overall. So most of TURBT in the United States are not done with blue light. Most cystoscopies in outpatient clinic are not done with blue.
Rick Bangs:	And what’s the obstacle keeping us from having broad access to narrow-band imaging and enhanced cystoscopies using blue light?
Dr. Yair Lotan:	Well, for narrow-band imaging for Olympus, or for CHROMA for STORZ, you have to have the appropriate scope, but most Olympus scopes that I’m familiar with come with the narrow-band imaging. So that access is actually pretty straightforward. And so a lot of urologists would have access to that. And as far as blue light cystoscopy, getting the hospital or the urologist to purchase equipment is really the obstacle. There really isn’t much obstacle. The Cysview is reimbursed by Medicare and other insurance companies. So even though there is a cost for the Cysview that needs to be instilled, physicians are reimbursed for it. So that should not be an obstacle. Obviously your physician has to order it, but the most expensive part is the capital equipment which runs around $60,000 to $80,000. So that has to be purchased either by the hospital or by the urologist.
Rick Bangs:	And what about the reimbursement on the patient side from an insurance perspective? Is it consistent with a standard cystoscopy or is it variable based on who your insurance company is? How would that work?
Dr. Yair Lotan:	Generally speaking, the urologist does not get paid more to do a blue light cystoscopy than a regular cystoscopy. That is probably one of the obstacles to adopting the technology because there is no added payment to purchase this capital equipment or for the additional time which is used for to do the blue light. So the patients, as far as I know, there is no added cost to the patient because the payment to the physician is not higher.
	Interestingly, in patients in hospital setting where you have a resection of a bladder tumor, the hospital does get paid an additional amount for blue light resections. On other hand, an outpatient surgical centers and in urology clinics, there is no additional payment for use of blue light cystoscopy. And they know setting is there additional payment for narrow-band imaging.
Rick Bangs:	Okay. And so the bottom line as a patient, should I shop around for one over the other? And if so, when and why?
Dr. Yair Lotan:	So this is a bit of a complicated question and one for which I certainly have a bias. I think that there are certainly scenarios where we know that a blue light is far superior. So if I had carcinoma in situ of the bladder, which is notoriously difficult to find with white light and is found 30% more commonly with blue light, I think that having a blue light cystoscopy during surveillance in the clinic where this could be missed is an advantage. And if there was one within a reasonable travel distance, I think that that would be what I would seek. There is some additional benefit in terms of detecting about 20% more cancers with blue light for non-carcinoma in situ.
	And if I was a patient who had frequent recurrences, I think a resection with blue light might mean that you might catch some additional ones. And we know that with blue light resections, the recurrence rate at one year is lower than with white light resections. So all things being equal, I think it makes sense. Is it worth a tremendous travel distance, additional costs, et cetera? I don’t know. That’s a personal judgment. Certainly a lot of our bladder cancer patients are frail. The average age for bladder cancer is over 70. It’s not always easy for people to travel, there’s costs associated with travel. And even in my practice, not everybody gets blue light every time.
	In patients who have a resection, the highest risk is at three months and six months. And if you haven’t recurred in that time point, then you’re less likely to recur at nine months a year or two years. So I try to focus my use of blue light on patients at highest risk, which means early on in their disease before we know whether or not they’re going to have recurrences, maybe in high-risk patients who have invasive tumors or multifocal tumors, high-grade tumors, carcinoma in situ. So I think that’s where it makes sense to use these resources.
Rick Bangs:	Okay. Yeah, that makes sense to me. So during the pandemic, we had a lot of patients that were unable to get into the clinic for routine screening and that would include cystoscopies and they had been told and people feel very strongly about doing follow up and keeping to schedule. Did we learn anything from the alternative scheduling that happened during the pandemic? Or is the jury still out on that?
Dr. Yair Lotan:	I think that when you say learned, is there evidence that delays in care were bad and harmful? Not yet. Do we think delays of care is bad and harmful? Yes, especially for patients with high-risk disease. I never shut down for the pandemic. I did cystoscopies in high-risk patients with a justification that when you come to my clinic and you’re wearing a mask and I’m wearing a mask and we all get our temperatures checked, the risk is relatively low. People had to go to the store. So if you have high-risk cancer, I did cystoscopy on you. If you had low risk disease, I may have delayed it by a month or two. But generally speaking, I tried not to miss time points for patients because I do think there’s value to it.
	Have there been papers published yet saying how bad was it for patients? No, and I’m not sure that it’s going to be easy to trace the magnitude of it because how would that if you delayed a month, it was going to be worse than if you did one month less? We don’t have a control group. Everybody was suffered under the pandemic. So it’s going to be a little difficult to prove this type of thing. But generally speaking, knowing that bladder cancer grows relatively rapidly and can progress, my thinking is, we’re probably going to have some people that are going to show some circumstantial evidence supporting that.
Rick Bangs:	Okay. So last question. I want you to look in your crystal ball and tell us what you see is the future for cystoscopy?
Dr. Yair Lotan:	Well, I don’t think it’s going anywhere anytime soon. I’ve hypothesized that maybe we’ll have better tools and that eventually maybe somebody will be able to put up a small camera in our bladder that will float around and periodically take pictures and send it to a computer. And some computer program with artificial intelligence will tell us, “Hey, we see something. You better go see your urologist today.” And that that camera will be exchanged every six months or so and that we wouldn’t have to look. Because we have technology in China where they can identify people’s faces and tell you who that person is and track them. We find these things to be maybe a little bit discomforting. But we also have telescopes that follow constellations and tell us this one moved and this one didn’t move. So why couldn’t you have a small little camera in your bladder and periodically which flashed low pictures of your bladder to a computer and tell us today you have to go have a look.
	I certainly don’t think that’s unreasonable. People do that. They’d swallow cameras to look at your intestine. So why couldn’t you put something in the bladder? That’s my thought that where things might head, but for now, I think in the meantime, I think there’s going to be plenty of urologists doing cystoscopies for at least the next five to 10 years. But technology sometimes moves in mysterious ways and maybe this concept will catch on.
Rick Bangs:	Okay, great. Thank you very much. This has been an incredibly fascinating look at cystoscopy and I’m sure our listeners are going to be much better informed about the various types of cystoscopy along with the pros and cons of each. So I want to thank you again for your time.
Dr. Yair Lotan:	Absolutely. Thank you so much.
Rick Bangs:	And in case people wanted to get in touch with you, could you share your email or other information that you would like people to have?
Dr. Yair Lotan:	Sure. Absolutely.  My email is just my name, yair.lotan@utsouthwestern.edu. You can easily find me on the UT Southwestern website. And certainly I’m happy to try to answer questions or if you want to come by Dallas and see me, I’m open for business.
Rick Bangs:	Okay, great. Just a reminder, if you’d like more information about bladder cancer, you can contact the Bladder Cancer Advocacy Network at 1-888-901-2226. That’s all the time we have today. Thanks for listening and we’ll be back soon with another interesting episode of Bladder Cancer Matters. Thanks again, Dr. Lotan.
Dr. Yair Lotan:	Thank you very much.
Voice over:	Thank you for listening to Bladder Cancer Matters, a podcast by the Bladder Cancer Advocacy Network or BCAN. BCAN works to increase public awareness about bladder cancer, advances bladder cancer research, and provides educational and support services for bladder cancer patients. For more information about this podcast and additional information about bladder cancer, please visit bcan.org.

 

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