David Lupo, MD, oversees a blue light cystoscopy procedure at the John L. McClellan Memorial Veterans Hospital in Little Rock, AR. The Central Arkansas Veterans Healthcare System is the first medical facility in Arkansas to offer the breakthrough technology for finding and identifying bladder cancer. Photo by Jeff Bowen, Central Arkansas Veterans Healthcare System for the April 29th, 2022, VAntage Point blog.
LITTLE ROCK, AR — Sometimes the right light makes all the difference in a cancer diagnosis. Early-stage cancers can be very challenging to see, but finding them before they advance provides the best chance for curative treatment with the fewest complications.
Under normal light, bladder cancer can hide in plain sight, and a normal cystoscope, which uses a thin tube with an affixed light and video camera, may not enable detection. A new tool blows bladder cancer’s cover by making even very small malignancies glow pink.
Physicians at the Central Arkansas VA in Little Rock and a small number of other VAMCs are using blue light cystoscopy to illuminate early bladder cancer and improve outcomes for veterans. The procedure employs a cystoscope equipped with both white and blue light. About an hour prior to the procedure, the physician inserts a special contrast solution into the bladder that makes cancer cells glow bright fluorescent pink under blue light. Normal tissue appears blue with the light.
The contrast makes spotting early, non-muscle invasive bladder cancer much easier and increases the accuracy and utility of a biopsy that can confirm the diagnosis. Blue light cystoscopy is used for patients with suspected bladder cancer or who have positive urinary cytology but no visible tumors using standard cystoscopy, as well as for patients being checked for tumor recurrence or who have multiple non-muscle invasive bladder cancer.
“This enhanced imaging procedure helps us to more easily find instances of bladder cancer, especially small or flat tumors, and offers better removal of bladder tumors when they are first discovered,” said David Lupo, MD, a urologist at the Central Arkansas VA. “In addition, it leads to fewer recurrences of bladder cancer and improved information to use to plan future care for a veteran.”
Increased Risk for Veterans
Bladder cancer is the VA’s fourth-most-diagnosed cancer, with 3,200 veterans diagnosed with the disease each year. While bladder cancer is the sixth-most-common cancer in the U.S., veterans have increased risk for many reasons, including age, sex and military exposures.
Bladder cancer typically occurs in individuals over the age of 55, and the average age at diagnosis is 73, according to SOURCE. It also is more than three times more common in men than women, so the advanced age and high proportion of men among veterans puts the population served by the VA at greater risk from the start.
Adding to the demographic risks, veterans are more likely to be or have been smokers, and smoking is the most common risk factor for bladder cancer. “In addition, some veterans may be at higher risk of developing bladder cancer than the general population, due to their exposure to certain chemicals during their military service,” said Courtney Franchio, program manager with VA’s National Oncology Program. Last year, the VA added bladder cancer to the list of presumptive conditions associated with exposure to Agent Orange in Vietnam and other conflict zones and to contaminated drinking water at Camp LeJeune between August 1953 and December 1987.
Exposure to per- and polyfluoroalkyl substances (PFAS), which were used in military firefighting foams and may have contaminated water supplies at some bases, may also increase the risk of bladder cancer. The VA and DoD continue to research the possible connection, Franchio added.
Signs and symptoms of bladder cancer include blood in the urine, painful or urgent urination, inability to urinate, abdominal or lower back pain, fatigue and unexplained loss of appetite or weight.
Improving Outcomes
“As VA urologists specializing in treating veterans with bladder cancer, we are always looking for advances in technology and treatment to provide the best possible outcomes for our patients,” said Lupo. Finding the cancer early is key to extending survival and reducing complications.
Bladder cancer typically originates in the transitional cells on the inner layer of the bladder and penetrates deeper into the muscle walls as it progresses. Early stage bladder cancer can be treated with transurethral resection of the bladder, in which the tumor excised from the bladder surface with a wire loop. Intravesical chemotherapy or intravesical bacille Calmette-Guérin, for high-grade tumors, often follows surgery. If a single tumor invades the bladder wall, a partial cystectomy or removal of part of the bladder may be used, often in conjunction with chemotherapy or radiation therapy.
Because of the high risk of recurrence, more-advanced cancer is treated with radical cystectomy or complete removal of the bladder. In men, this procedure also involves removal of the prostate and seminal vesicles. In women, the ovaries, uterus and some of the vagina may also be removed. After radical surgery, patients require an alternative system for the collection and elimination of urine, which may include a pouch constructed of intestinal tissue inside the body or a leak-proof bag worn outside the body.
“This new technology could add years to the lives of our patients,” said Margie A. Scott, MD, director of the Central Arkansas Veterans Healthcare System. “We are proud the Central Arkansas Veterans Healthcare System has some of the best doctors and nurses in the country and offers the latest care options to our veterans.”
