Stephen Williams: Thank you very much for having me, the UroToday team, and always a pleasure to be with you, Dr. Kamat.
Ashish Kamat: So first off, been a pleasure for me to be part of your journey, but you're doing so many great things now in so many different ways, actually. One of the ways in which you're really helping not just the community of urologists, but the patients per se and the whole system is shining light on things that are relevant when it comes to a financial burden that the system faces. So really excited to see and hear what you have to say about the BRAVO study, the cost of care and outcomes with blue light.
Stephen Williams: Absolutely. It's my pleasure to see how everything has evolved from our journey together. It really did start with us at MD Anderson and now transitioning this and growing other future leaders. So one of our residents, Dr. Nasrallah was the lead author in this. So I definitely want to give credit where credit's due, as well as our national VA team that's based out of Durham. So with that being said, I'll go ahead and get started here. We'll start with the outline briefly. We'll go over the study design, methodology, and then dive into the results and ultimately hopefully give our listeners an understanding, not only the discussion, but I think the impact of our findings as we're all starting to understand how meaningful not only the oncologic outcomes are, but really marrying with the economic considerations that we all are responsible stewards for. So diving right in, the study design and the methodology, this is a retrospective cohort study of non-muscle-invasive bladder cancer patients that were treated at the Veterans Affairs Healthcare System nationally from the period of 1997 to 2021. Really the premise here is to understand blue light cystoscopy after diagnosis compared with white light cystoscopy only. In these patients, we use propensity score matching to identify 311 blue light exposed patients to 311 white light exposed patients.
The outcomes that we're considering here included one, two, and five-year total and category-specific healthcare costs, non-muscle-invasive bladder cancer recurrence, and recurrence-related costs offsets to truly understand the economic considerations in using blue light cystoscopy as compared to white light. The diagram here really illustrates we had excellent matching between these two cohorts. The results, as we could see, blue light cystoscopy had lower recurrence rates, approximately 20% versus 30%, which was significant, as well as also had fewer inpatient visits. We also found that blue light cystoscopy, interestingly enough, had fewer emergency room visits. However, blue light cystoscopy had higher five-year total costs, approximately 108,000 US dollars versus 66,000 US dollars. This was driven largely by higher outpatient costs, approximately 90,000 versus $55,000 respectively. The cost offset analysis includes our five-year adjusted blue light cystoscopy exposed patients about $67,000, and five-year adjusted blue light versus white light cystoscopy cost difference was about 721 US dollars. The results of this diagram really show our total costs over time at one, two, and five years on type of cystoscopy.
What's important to note here are also too, the substantial costs of care of these patients over a five-year span, regardless of type of cystoscopy that was used. On the diagram on the right side of the screen here, you could see our cost differences with the incremental costs, the cost of recurrence, and then of course adjusting for ER and inpatient cost difference to really give, as you could see on the diagram here, our net cost difference as was previously mentioned. I know this slide is very difficult to see from the table, but to really give a high level summary, the costs per year were higher in the blue light cystoscopy group with the median 27,000 versus 20,000, which were primarily driven by outpatient costs as previously explained, which were 23,000 versus 16,000. Inpatient costs did not differ between the groups though, with no cost differences observed by race as well. Among patients with high-risk disease, and these were approximately 60% of our cohort, the costs were significantly higher compared to those with low-risk disease. The take-home message, really and the impact here, is blue light cystoscopy exposure was associated, and as previously we published as well with lower risk, were lower risk of recurrence among these patients.
Then also five-year unadjusted costs were higher for blue light cystoscopy, primarily driven by increased outpatient utilization, but also in the blue light cystoscopy patients, there were significantly more patients that underwent BCG or intravesical chemotherapy in that group as well. Recurrence-related cost offsets resulted in near cost neutrality over five years. These findings really help inform value-based adoption of blue light cystoscopy and non-muscle-invasive bladder cancer care. Our findings were published in the Journal of Urologic Oncology. Once again, I really want to celebrate our junior resident that is going to be applying for Society of Urologic Oncology Fellowships this year, Dr. Nasrallah, as well as our outstanding VA team that is based out of Durham. Then really a good friend and mentor of mine and colleague, Dr. Freedland, who I've worked with over the years to help really build hopefully more of a story behind not only the economic sequelae, but also married with the oncologic outcomes. Thank you.
Ashish Kamat: Thanks so much, Stephen. That was very clearly presented. Of course, I wouldn't expect anything less. For the benefit of folks that are listening, that people with blue light really fall into two camps, right? Those that believe that, yes, it helps with detecting recurrences, and that's why we should use it. The cost value proposition favors the patient's cancer journey. So that's a group that adopts the blue light technology quite easily. Then there's the other group, and I think that's where this data is useful. I'm going to ask you a couple questions pointedly there. Another group that says, well, the upfront cost is a lot and you're adding extra cost and it's extra time. It doesn't really help in the long term and it's not cost-effective. Do those people or that group of people, how would you reframe that discussion based on the data that you just presented?
Stephen Williams: Certainly. Well, I think you bring a great important point. Cost-effectiveness analysis is much different than our descriptive analyses that we performed here. What do I mean that by, it's a quality-adjusted life years quality, as well as other metrics that we use in cost-effectiveness analysis research. In that group, I would have to agree with we have to be very careful on the types of patients that we can attribute true value and derivation. This study itself had, like I mentioned before, roughly 60% of patients were high-risk non-muscle-invasive bladder cancer versus 40%. As we noted as well, and I mentioned those high-risk patients also too, had substantial cost versus low risk. Also, too, perhaps those patients more readily identified leading to decreased risk of recurrence in the overall cohort. When you're looking at cost over outcomes, these data show net cost neutrality, which is important because as an organization ourself, we're a public university, but really just everywhere we go across the globe, we're becoming increased cost-conscientious, limited resources, limited funds. Then obviously as we're coming with more increased use of novel treatments, this is going to unmask even a greater opportunity where perhaps using technology that may have an upfront cost can justify it and particular groups may derive the most benefit. My honest opinion from this study, it's objective. Further cost-effectiveness analysis research is needed in this arena, but we can support perhaps in patients that have high-risk non-muscle-invasive bladder cancer can derive a particularly value-added benefit, which approaches, like I mentioned before, the cost neutrality, which was quite intriguing from this study.
Ashish Kamat: Yeah. Things are getting more and more expensive, right? I mean, when we're looking at adding IO to BCG or treatments that are coming after a patient has had a recurrent tumor post BCG, BCG-unresponsive setting, the costs are getting quite astronomical. Of course, that's a whole different question. Is that cost worth it to the patient, to the healthcare system? Those costs sometimes go into the millions of dollars. This cost delta is, in my opinion, and again, you've shown it actually gets cost neutral, not that much to begin with. So two questions to follow that up on my statement, Stephen. A, do you use blue light in your practice and B, do you factor in cost when you're making such clinical decisions?
Stephen Williams: Sure. Well, both of those actually tie quite well into our program. So yes, I do use a blue light cystoscopy, both in the operating theater as well as in the outpatient clinic with flexible blue light. I tailor that, and I have to owe this to my training by you and as well as several others, is being really selective. Then using the trial data that you've published that have helped show and delineate which patients may derive the most benefit. The other thing as well as bringing obviously new technology in our system as an example, that was one of our first studies where I had to decrease the sticker shock price. Actually I used ... This is a great example of using whatever talents, physicians, leaders, their expertise. So I used my health services research background to do a number needed to treat, to approach where we could derive profitability from bringing on additional treatments by the decreased risk of recurrence.
Which ended up being approximately 50 flexible blue light cystoscopies in this case to justify the upfront costs. The good thing about that is not only that our study was used primarily to drive our introduction of flexible blue light to our organization, but also it was really neat, the findings were published. So hopefully others can help understand and then use that methodology as we're all being challenged on bringing not only newer technology, but really costly agents. I know we're doing, or you are as well and the team, you've allowed me to participate in this and really learn from your group. Then hopefully globally I'm seeing just wonderful partnerships to derive, learn, and really help inform not a one-size-fits-all approach, but really tailoring precision-based medicine, precision-based treatments, diagnostics. Then being really stewards in not only oncologic outcomes, but the costs that are introduced in treating one of the most costly cancers.
Ashish Kamat: I couldn't have said it better, Stephen. That was very well said. Thanks for taking the time. Always a pleasure. Hope to see you soon.
Stephen Williams: Likewise. Thank you so much for having me.