Sponsored by Photocure, Inc.

An Interview with Shreyas Joshi M.D., M.P.H.

With an enhanced ability to visualize NMIBC lesions using Blue Light Cystoscopy (BLC®) with Cysview® (hexaminolevulinate HCl), Shreyas Joshi MD, MPH, recounts a recent case of a younger patient with recurrent non-muscle invasive bladder cancer (NMIBC) whose course of treatment was greatly influenced by the enhanced tumor detection provided by BLC with Cysview.

“I’m seeing a patient with some repeat CIS and hybrid T1 in the trigone and bladder neck…normally for a young patient like that I’d strongly recommend bladder removal, and obviously he doesn’t want that. But I was able to comfortably say, after using BLC with Cysview, that it doesn’t look widespread – it looks very focal, so let’s try salvage therapy. I wouldn’t have made that call had I not had something else telling me that this is a reasonable approach to take.”

Dr. Shreyas Joshi is an Assistant Professor in the Department of Urology at the Emory University School of Medicine where he serves as the Director of the Bladder Cancer Program. With expertise in multimodal surgical approaches to high-risk bladder cancers, Dr. Joshi is eager to share valuable insights he’s gained while using BLC with Cysview for enhancing the detection of NMIBC.

The effective detection and removal of cancerous tissue when performing transurethral resection of bladder tumor (TURBT) is key to improving patients’ prognosis in NMIBC.,  BLC with Cysview is clinically proven to provide better visibility than White Light Cystoscopy (WLC) alone.^{1, 2}  By preferentially accumulating in bladder cancer cells, Cysview is an optical imaging agent that causes bladder cancer cells to glow pink in blue light. For urologists, this fluorescence can mean improved diagnosis and subsequent disease management following initial resections and enhanced surveillance following treatment.³

Dr. Joshi recognizes the benefits of using BLC with Cysview, identifying several key patient types that he finds it particularly useful for – patients with very small NMIBC lesions, those with carcinoma in situ (CIS), and those undergoing post-treatment surveillance. Cysview’s innovative mechanism of action sets the BLC procedure apart from more dated methods like WLC that has traditionally been the standard technique for the detection of bladder cancer.

“BLC with Cysview is a way to visualize cancer within the bladder more effectively, especially lesions that are otherwise more difficult to identify using just regular white light. Certain patients who have cancers that are either very small or it’s CIS. I explain CIS to my patients like this…it’s like having off-white paint on a white wall; it’s sometimes very difficult to see and the blue light helps it pop out.”

With this mechanism allowing for more precise identification of cancerous tissue, BLC with Cysview can be utilized in patients across the NMIBC disease-care continuum. BLC with Cysview can be considered for patients undergoing an initial TURBT where NMIBC is suspected, thereby providing guidance for complete resection, and allowing for more accurate tumor typing, staging, and grading. Following treatment, it can play a key role in the ongoing surveillance regimen used to detect possible recurrence.

The positive impact that BLC with Cysview has for patients is significant for Dr. Joshi, particularly in cases where potential interventions, like cystectomy, can be life-altering.

“Whether I see something, or if I don't see something, BLC with Cysview helps me determine whether my management is correct. I think that that's meaningful to me.”

Blue Light Powered by SAPHIRA™

With the recent introduction of the improved SAPHIRA™ BLC technology system, Dr. Joshi is immediately impressed by the noticeable enhancements in the quality and clarity of bladder cancer visualizations, preferring it to the previous BLC system. Surgeons rely on these images to support the removal of as much abnormal tissue as possible to send to the pathologist. As a result, there can be a more accurate diagnosis, which in turn, guides management decisions. These technology improvements can have positive, consequential effects on patient outcomes.

Dr. Joshi is also encouraged by significant improvements in the SAPHIRA™ system’s set-up, usability, and reliability compared to the previous system. Given the pressures often faced in the operating suite, having a reliable system with a user-friendly interface means more attention can be focused on where it matters most—the patient.

“I really like SAPHIRA™ compared to the old tower. It provides a remarkable difference in picture quality and clarity. It is simply better all around. The system is easier to set up and the quality of the image, even with white light, is so much better.”

– Shreyas Joshi – MD, MPH

1. Stenzl A, Burger M, Fradet Y, et al. Hexaminolevulinate Guided Fluorescence Cystoscopy Reduces Recurrence in Patients with Nonmuscle Invasive Bladder Cancer. J Urol. 2010;184(5):1907–1914.
2. Daneshmand S, Patel S, Lotan Y, et al. Efficacy and Safety of Blue Light Flexible Cystoscopy with Hexaminolevulinate in the Surveillance of Bladder Cancer: A Phase III, Comparative, Multicenter Study. J Urol. 2018;199(5):1158–1165.
3. Cysview [prescribing Information]. 2019:1-4.

Dr. Shreyas Joshi is a paid Photocure consultant.

Indication for Cysview® (hexaminolevulinate HCl)

Cysview is an optical imaging agent indicated for use in the cystoscopic detection of carcinoma of the bladder, including carcinoma in situ (CIS), among patients suspected or known to have lesion(s) on the basis of a prior cystoscopy, or in patients undergoing surveillance cystoscopy for carcinoma of the bladder.

Cysview is used with the KARL STORZ D-Light C Photodynamic Diagnostic (PDD) system to perform Blue Light Cystoscopy (BLC^®) as an adjunct to White Light Cystoscopy.

Important Risk & Safety Information for Cysview®

Limitations of Use

Cysview is not a replacement for random bladder biopsies or other procedures used in the detection of bladder cancer.

Warnings and Precautions

Anaphylactoid shock, hypersensitivity reactions, bladder pain, cystitis, and abnormal urinalysis have been reported after administration of Cysview. The most common adverse reactions seen in clinical trials were bladder spasm, dysuria, hematuria, and bladder pain.

Contraindications

Cysview should not be used in patients with porphyria, gross hematuria, or with known hypersensitivity to hexaminolevulinate or any derivative of aminolevulinic acid. Cysview may fail to detect some malignant lesions. False-positive fluorescence may occur due to inflammation, cystoscopic trauma, scar tissue, previous bladder biopsy, and recent BCG therapy or intravesical chemotherapy. No specific drug interaction studies have been performed.

Use in Specific Populations

Safety and effectiveness have not been established in pediatric patients. There are no available data on Cysview use in pregnant women. Adequate reproductive and developmental toxicity studies in animals have not been performed. Systemic absorption following administration of Cysview is expected to be minimal. There are no data on the presence of hexaminolevulinate in human or animal milk, the effects on a breastfed infant, or the effects on milk production. The development and health benefits of breastfeeding should be considered along with the mother’s clinical need for Cysview and any potential adverse effects on the breastfed infant from Cysview or from the underlying maternal condition.

Use of the KARL STORZ D-Light C Photodynamic Diagnostic (PDD) System

Cysview is approved for use with the KARL STORZ D-Light C Photodynamic Diagnostic (PDD) system. For system set up and general information for the safe use of the PDD system, please refer to the KARL STORZ instruction manuals for each of the components.

Prior to Cysview administration, read the Full Prescribing Information and follow the preparation and reconstitution instructions.