Ali Nasrallah: All right. Thank you very much, Dr. Kamat, and the UroToday team for having me. I have the pleasure of presenting a work titled Costs of Care and Oncologic Outcomes Associated with Blue Light Cystoscopy in an Equal-Access Setting: Results from the BRAVO Study. This study was conducted with support from Photocure. So briefly, as we know, bladder cancer is not only high in prevalence, but also associated with significant treatment costs. In particular, recurrent NMIBC management was estimated to cost about $31,375 per patient per year in 2021. And blue light cystoscopy is a diagnostic technology that helps improve tumor detection and is associated with lower recurrence rates. As was shown in the BRAVO-2 study. We aimed, in this case, to evaluate the cost of blue cystoscopy exposure and to determine its cost-effectiveness when accounting for recurrence prevention.
So the study population was derived from the VA healthcare system with pathologically-confirmed NMIBC between 1997 and 2021. The two cohorts were patients who were exposed to BLC at any time versus exclusively undergoing white light cystoscopy. Propensity score matching yielded 311 patients in each cohort. And we compared the total and category-specific costs at one, two, and five years. And then performed a cost offset analysis using a published economic model. So the table here compares our two cohorts which had similar demographics and clinical factors after matching. 98% were male, 10% were African American, 82% were smokers, and we note that 61% of the cohort had high-risk disease. In total, about 25% of patients had a recurrence of bladder cancer, 20% in the BLC group, and then 30% in the white light group. BLC exposure was associated with a higher likelihood of receiving intravesical therapies without increased rates of cystectomy or chemoradiation. And to note, given the equal-access setting in the study, no differences were noted between racial groups as well.
The Kaplan-Meier curves here show that the risk of recurrence was significantly lower following blue light exposure with a recurrence-free survival at three years at 75% versus 67%. And the multivariable analysis showed a significantly lower risk of recurrence with a hazard ratio of about 0.62. With regards to the progression of disease, while the number of events trended in favor of BLC exposure, statistical significance was not achieved within the timeframe of the analysis. So with regards to healthcare utilization and the costs, the BLC cohort had fewer inpatient visits, fewer ER presentations, but overall higher costs in total at one, two, and five-year intervals. The five-year total costs were 108,411 US dollars for blue light versus $66,734 for white light. This was mainly driven by the increased outpatient expenditures, likely due to the higher usage of intravesical chemotherapy and BCG. Our cost offset analysis accounting for inpatient and ER savings, as well as recurrent NMIBC management savings, yielded an adjusted BLC exposure cost of $67,445, which results in a net adjusted cost difference of $721.
So in summary, the real-world equal-access setting that we had, BLC exposure was associated with lower recurrence risk, was also associated with higher total costs, mainly driven by increased outpatient use of intravesical therapies. When accounting for recurrence cost offset and healthcare utilization savings, BLC exposure approached a near net cost neutrality at $721 per patient over five years. So a take-home message is that blue light cystoscopy exposure is associated with higher total costs, but approaches cost neutrality when accounting for recurrence cost savings. Thank you once again.
Ashish Kamat: Thanks so much, Ali. That was very nicely done. Again, the BRAVO study replicates what we've known from the various Phase III, Phase IV studies with blue light, but it's good to see this in the real-world setting. Did you look at... I mean, because it makes sense, exposure to blue light, using blue light to detect more tumors will reduce recurrences, and yes, it might increase cost, but it's a risk-benefit ratio for the patient. Did you look at the metrics such as, for example, cost per recurrence and how it plays out in that setting?
Ali Nasrallah: Yeah, so that was something we were curious to look at. One of the limitations of the data that we did have was that the number of events of blue light that the patient was exposed to was not accounted for. So that ended up being a limitation that did not enable us to have that analysis done, an accurate level, or a level of accuracy that we would like to show. So instead to take a more safe approach at looking at the cost from a more holistic standpoint, we took the just total costs, everything that the patient is getting exposed to as far as treatments and otherwise as far as healthcare utilization, and then utilize that with published recurrence prevention or recurrent NMIBC cost analyses in order to derive the adjusted cost difference. The cost per recurrence analysis would have been also useful, but unfortunately with the limitation that we have with how the data is set up, that would not be possible to do.
Ashish Kamat: Sure. I guess that's a limitation of the dataset. But if you actually look at the cost of, for example, BCG plus another therapy, say BCG plus IO, that cost is phenomenal, and you're reducing recurrences again by five or 6%. Here, with blue light, you do have an increased cost. It's not a huge cost, and be interesting to see if you could model reduction in recurrences for blue light compared to say reduction in recurrences cost with some of the newer data that's been published. It'd be very interesting to see how it pans out in that arena. What are your plans for this data? What's next?
Ali Nasrallah: So next, we're looking at publication of this data, and we're hoping that this will drive more discussion within the non-muscle-invasive bladder cancer realm, especially with all the new intravesical therapies and options that are being offered to patients and to urologists alike in terms of immunotherapies that are present, IO, pembrolizumab, now also with the BRIDGE study accrual coming up, and the results hopefully shortly. This should help engage in more discussions as far as bringing in costs of care and trying to minimize those costs on the patients. Given how burdensome this disease is, it becomes a chronic disease state, more or less the patients are managing long-term, preventing recurrences seems to be part of that. Should be part of that equation. Quality of life, I believe, is another angle that I would hope to tackle in the future is how many quality-of-life years we're able to add to patients by reducing the recurrence burden, trips to the OR. And then hopefully by getting them on the more appropriate treatment pathways earlier, we can see improvement in that.
Ashish Kamat: Great. Well, nicely done, Ali. Congratulations and best of luck.
Ali Nasrallah: Thank you very much, Dr. Kamat.