Sam Chang: Hi. My name is Sam Chang. I'm a urologic oncologist in Nashville, Tennessee at Vanderbilt, and we are privileged to have Dr. Boris Gershman, Dr. Sia Daneshmand focusing on actually some of the work that's been done looking at actually Cysview blue light cystoscopy. But originally, I think you all looked at-- or Dr. Gershman, you've focused on how effective are the current risk stratification models that we have as we incorporate them, as we utilize blue light cystoscopy because as we know, detection, evaluation, and actually the use of this may decrease recurrence, et cetera.

So first of all, thank you for spending some time with us. And we look forward to hearing from both of you. Give me the highlights of what you presented at AUA 2025.

Boris Gershman: Sure, well, first of all, thanks so much for having me and inviting us to talk about this. I think it's a really important topic. Risk stratification is critical for the appropriate personalized management of bladder cancer. Obviously, it's a heterogeneous disease with a really long natural history, and the traditional risk prediction models we use, the EORTC and CUETO risk tables are about 20, 25 years old. And so the question was whether they apply in contemporary patients.

In particular, as you mentioned, blue light cystoscopy has been associated with lower recurrence rates because it helps detection of tumors at the time of resection, and it's advocated by clinical practice guidelines. And so we sought to evaluate whether these tables really performed well in contemporary patient populations treated with blue light cystoscopy.

Sam Chang: So as you look at those patient populations, Sia, in the day-to-day, how often do you use CUETO, how often do you use EORTC in terms of the actual calculation versus getting an idea of what they thought was important and how that impacted on recurrence or progression? Can you tell me what you do day to day?

Sia Daneshmand: Yeah, so certainly the concepts are there. And we use the concepts all the time. Whatever variables went into those risk stratification tables, we are using every day. There's just a lot of information out there. So to be honest with you, I don't use the actual calculator itself to calculate risk. There are other ways to calculate risk but it is a good way to do that.

But like Boris said, these are old. And we really need contemporary risk calculators because these patients also were treated 20 years ago. So treatment has changed regardless of blue light.

Sam Chang: You have so many, and I think it's important also that we look at risk of recurrence versus risk of progression because there are two different kinds of risks. So Boris, tell me about what you presented at the AUA regarding initial findings regarding these risk stratification systems.

Boris Gershman: Sure, yeah. So we utilize the multi-institutional blue light cystoscopy with registry, which is actually a fantastic resource for a number of centers across the country.

Sam Chang: And you're not saying that just because Sia is sitting next to you.

Boris Gershman: No, not entirely.

Sam Chang: No, exactly.

Boris Gershman: No.

Sam Chang: But incredibly important huge effort regarding real world data. I think really, that's become one of the standard bearers of hey, this is how much a registry can help you get information. And so by gathering all that, and then gathering it prospectively and then being able to evaluate it, I think is really important. So tell us what you found.

Boris Gershman: Yeah, so we included about 900 patients, nearly 900 patients who had non-muscle invasive bladder cancer, either Ta, T1 or CIS. And we basically calculated their risk scores according to the EORTC risk tables. And then we did a couple of things. One, we examined whether the risk groups themselves because they stratify patients into risk categories, for instance, low, intermediate, and high. Whether the risk groups were stratifying patients who were treated with cystoscopy.

And we also examined how well the actual predictions for recurrence and progression rates at each time of follow up-- 1, 2, 3, 4 and 5 years correlated with what was observed in the real world data. And so what we found was interesting for the EORTC, the risk groups did actually stratify where the higher risk patients had higher rates of recurrence and progression. But for CUETO, they were actually all over the board. So they didn't really stratify as we would expect them to.

For both the EORTC and CUETO risk tables, though, the specific predictions of recurrence and progression at various follow up times was not accurate to what we actually saw in the data. So the EORTC tended to overestimate rates of recurrence and progression, which is intuitive because blue light and other techniques that have been adopted in the last 20 years have decreased recurrence and progression rates, or at least we like to think so.

And the CUETO estimates were sometimes over, sometimes underestimating, and not really very consistent. And so these observations highlight the need for developing new contemporary tools to help prognosticate recurrence and progression risk in contemporary patients and in particular, undergoing blue light cystoscopy.

Sam Chang: And obviously, in no way are we attempting to malign these stratification tables. These were established, just as you said, decades ago on large patient population data and have served us well in terms of helping to start an important process of risk stratification. So Sia in the day-to-day world then, looking at this data, you obviously are concerned about the inconsistency of CUETO.

You understand, just as Boris said, that the EORTC guidelines or risk stratification tend to overestimate how often this would occur in light of the fact that, OK, that was white light cystoscopy, different techniques, et cetera. What do you now think about when you see an individual patient that you've been treating with blue light? What do you tell them that is going to help determine whether or not they're going to recur or not, or whether or not they're going to progress or not?

Sia Daneshmand: Yeah, I think these are very important concepts. First of all, you need to tell patients because that's the first thing you tell them on a newly diagnosed bladder cancer patient that this is a highly recurrent tumor. Then the next question is how often? What are the rates of recurrence? So it is important to risk stratify patients and use modern tools to do this.

So I'm really very happy to see that Boris has been working on this to develop new risk stratification models so that we can use these. And I'm also happy to see that we've improved over the last 10, 20 years.

Sam Chang: Oh, fantastic.

Sia Daneshmand: And really it adds to the data that we have on blue light cystoscopy and how multiple different studies, no matter how you look at it, it performs better than white light cystoscopy in terms of recurrence. We haven't quite proven the progression part yet with blue light cystoscopy, but registries like this hopefully will help us do that.

Sam Chang: Yeah, I think, I mean, the way that I counsel patients. And if I'm a patient, why would I not want a therapeutic slash diagnostic approach that could help find tumors better, easier. That then leads to, I mean, it almost becomes a tautological argument that, hey, you're going to find something and you treat it. You're less likely to have disease come back or completely eradicate disease.

I think when it comes down to full disclosure, I use blue light cystoscopy, honestly, on the majority of my TURBTs now, and it has become, I hate to say it, but I rely on it at times.

Sia Daneshmand: Absolutely.

Sam Chang: So the fact that we've seen this benefit probably over time with the combination of things, I think is a promising finding--

Sia Daneshmand: Yeah.

Sam Chang: And we look forward, Boris, to more work with this registry. And I know you also had a demonstration of hey, what can we do in terms of setting up another type of risk stratification table? And we should discuss that at some other time with UroToday. So thank you guys so much for spending some time with us.

Sia Daneshmand: Thank you.

Boris Gershman: Thanks so much for having us.