HAL Does Not Improve Bladder Cancer SurvivalIt is associated with prolonged recurrence-free survival, however, compared with white light cystoscopy.
Hexaminolevulinate-enhanced fluorescence (HAL) cystoscopy significantly increased the rate of recurrence-free survival in patients with muscle-invasive bladder cancer in a German study. HAL did not decrease the time to progression or tumor-specific survival, however.
Christian Stief, MD, PhD, Professor and Chairman in the Department of Urology at Ludwig Maximilians-University in Munich, presented findings at the 2009 European Urology Forum in Davos, Switzerland. In a study conducted at Regensburg University Hospital in Regensberg, Germany, researchers examined 21 patients with HAL cystoscopy (Hexvix, Photocure ASA, Oslo) and 25 with white-light cystoscopy.
Subjects had multifocal lesions, concomitant carcinoma in situ (CIS), and/or tumors greater than 3 cm in diameter. After a follow-up of eight years, recurrence-free survival was significantly greater in the HAL group compared with the white-light group (41% vs. 27%), but the mean time to progression and the tumor-specific survival rate were similar in the two groups.
A North American study published two years ago showed that HAL cystoscopy could detect more CIS sites per patient than white-light cytoscopy (J Urol. 2007;178:68-73). However, the same study also indicated that HAL cystoscopy did not identify additional patients with CIS who did not already have an abnormality on standard white-light cystoscopy.
Other studies have indicated that while HAL cystoscopy can identify more noninvasive Ta-stage bladder tumors per patient than white light, it neither reduces the rate of progression to invasive disease in people with Ta tumors nor improves detection of T1 tumors compared with white-light-guided transurethral resection (TUR) (J Urol. 2007;178:62-67 and Urology 2007;69:675-679). The ability of HAL cystoscopy to identify more bladder tumors does lead to a 20%-30% lower recurrence rate following TUR for Ta tumors.
“I find it hard to conclude [based on these data] that Hexvix alters outcomes in the muscle-invasive disease cohort,” commented Brant A. Inman, MD, Assistant Professor of Surgery at Duke University Medical Center in Durham, N.C.
“One benefit that Hexvix might have, however, is the ability to detect patients at high risk of progression—that is, those with multifocal or high-grade lesions and/or frequent recurrences. These patients could then be treated more aggressively with intravesical therapies or might be offered cystectomy at an earlier time point than usual.”