An interview with Daniel Canter, M.D.

The FDA recently gave clearance to narrow-band imaging (NBI) for claims of improved visualization of bladder cancer during endoscopic diagnosis and treatment. What are your thoughts on this development?

Anything we can do to improve the earlier detection of bladder cancer, specifically the detection of occult lesions in patients with de novo and recurrent bladder cancer, is welcome. Overall, there have been few advancements in the detection and treatment of bladder cancer. NBI can help detect these lesions; it has been documented to do so to the tune of 24% additional occult tumors and 28% additional carcinoma in situ (CIS or difficult-to-detect flat lesions).

If a practice or hospital was thinking of investing in NBI, what would be the best reasons for doing so?

This would be an important investment because it can improve outcomes. With the digital cystoscope, you can use the cystoscope for not only white light cystoscopy but also NBI. You can toggle between the 2 imaging techniques to do a thorough cystoscopic examination of the bladder. NBI does not require the use of dyes, which is convenient. What is also nice about NBI technology is that it is available in both the inpatient and outpatient settings.

Historically what have been some challenges of diagnosing bladder cancer and what impact will NBI have on addressing those?

Historically, while considered the gold standard, white light cystoscopy would miss difficult-to-detect occult or flat lesions. These types of recurrences would be missed not infrequently on white light cystoscopy. The addition of NBI should help to detect these lesions earlier and should translate into improved patient outcomes.

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What benefits that you haven’t yet mentioned might be derived through NBI use in terms of treatment costs? And in terms of patient outcomes and/or quality-of-life?

Bladder cancer is the most costly cancer to treat. The high rate of its recurrence and the disease’s potential for progression requires long-term patient monitoring, which accounts for its cost as well as increasing patient discomfort and anxiety. NBI can potentially improve patient outcomes which can hopefully translate into an improved quality of life for a variety of reasons.

Also, if visualized early enough, NBI has the potential to reduce expenses. For example, using a cystoscope with NBI capabilities, small tumors that may have been missed on a surveillance cystoscopy could be fulgurated in-office and could prevent OR visits.

How soon do you think NBI will be a standard-use technology among urologists diagnosing and treating bladder cancer?

With any new technology, it’s hard to predict how readily it will be adopted. I do think these types of techniques are being recognized as an important adjunctive part of endoscopic follow-up for patients. An improved view into the underlying vascularity of the lining of the bladder means an improved ability to detect and treat not just the obvious tumors but also the lesions that may have been missed with traditional white light cystoscopy only. This is something most urologists have known and would agree with, but it is now backed by the FDA.

What technical challenges are presented by the anatomy and physiology of the bladder? Is NBI helpful in dealing with these anatomy-specific challenges and how?

The bladder, as with any hollow organ, poses its own unique set of anatomic challenges for endoscopic procedures. As we have said, many bladder cancer lesions can be missed during white light cystoscopy, thus the use of any technology to aid in the visualization of these lesions is needed.

With NBI, the isolation of the blue and green light bands of wavelength allows for ready visualization of blood patterns. The blood absorbs these colors — blue light [415 nm] highlights the shallow capillaries and green light [540 nm] highlights deeper veins. Getting a good look at blood vessel patterns is important to help identify occult lesions or tumors.

How can the urology community get the word out about NBI to referring physicians, such as those at family practices?

PCPs give referrals to urologists not usually for bladder cancer but for hematuria, and then a portion of these patients will be diagnosed with some type of urologic cancer, such as bladder cancer. General or community urologists do an outstanding job of taking care of patients with bladder cancer, but their access to newer techniques and technology can often be limited by the cost of updating their equipment for things like NBI.

So, I think it’s important that community urologists know about NBI and do what they can to learn more about it. If they don’t have the capability for NBI in their practice, it may be worthwhile to refer patients who are not responding to treatment or recurring at a faster rate to places where NBI is used to help detect and treat potential occult lesions. Ultimately, we all want better outcomes for our patients, and technologies like NBI should help us achieve that.

Daniel Canter, MD, is an associate professor of urology and vice chairman of the Urologic Institute of Southeastern Pennsylvania, a partnership of the Fox Chase Cancer Center and the Einstein Healthcare Network.  He has published extensively in the field of urologic oncology with over 100 peer-reviewed publications and 15 book chapters.  Dr. Canter is the recipient of numerous awards and has been invited to many regional, national, and international meetings to lecture and give presentations.