Photodynamic Diagnosis of Bladder Cancer
"Streamlining Cancer Surgery"
Cancer Research UK has recently reported that 10,090 people were diagnosed with bladder cancer in 2007, with 150,000 people worldwide dying from this illness in 2008. According to Cancer Research UK, bladder cancer is the fourth most common cancer in UK men, with around 7,300 new cases diagnosed each year. Cancer Research UK's report states that around 57% of men and 47% of women with bladder cancer survive their disease for at least five years after diagnosis, with the Cancer Reform Strategy (2010) reporting that in 2008 there were at least 1.6 million cancer patients living with or beyond a diagnosis of cancer in England. The Cancer Reform Strategy (2010) also stated that the number of cancer survivors is increasing by 3% a year. Therefore the growing demand on the NHS indicates the need to introduce more streamlined diagnostic services into the overall commissioning cycle to ensure efficiencies in cancer surgery can be achieved.
The results of this technology implementation project demonstrated that there are significant challenges with successfully embracing a diagnostic technique which provides an innovative supplement to the standard surgical treatment for non-invasive bladder cancer (known as a Transurethral Resection of a Bladder Tumour or TURBT). The Photodynamic Diagnosis of Bladder Cancer (PDD) (sometimes referred to as ''blue light") technology uses a photo-sensitising chemical to enable tumour tissue to be more easily identified compared to conventional diagnostic techniques. This enables a better distinction during the TURBT procedure between tumour and normal bladder lining, helping to identify lesions and suspicious areas that may otherwise have not been seen using conventional white light cystoscopy. As PDD facilitates a more thorough initial TURBT, patients are managed more effectively due to an enhanced assessment of the spread of further disease and risk, which may result in subsequent surgery later on in the pathway of care.
This How to Why to Guide aims to provide practical guidance to enable the successful implementation of the PDD and to help you to realise the benefits this service improvement can bring. The guide has been specifically designed to save you time, improve patient outcomes and enhance overall productivity.
In this site you will find:
- Evidence Base to help you understand more about the diagnostic technique and the technology that sits behind it.
- Support to put together a Business Case.
- The Roadmap to service implementation and the necessary supporting Policy that implementation aligns to.
The guide also includes useful information which will assist NHS organisations in developing this service, which include:
- PDD Introduction to Technology.
- The Benefits 'vs' Barriers of adopting this technology.
- Supporting Evidence Base.
- Overcoming perceived Benefits 'vs' Barriers.
- How to effectively work through the Procurement of this technology and its associated consumables.
- Key Policy areas that will be impacted on as a result of implementation.
The Technology Explained
The current standard for the initial treatment of non-muscle invasive bladder cancer is a TURBT (transurethral resection of bladder tumour). This surgical procedure involves the insertion of an instrument called a resectoscope into the bladder to carry out an initial visual endoscopic examination or cystoscopy during which tumour is visually located and then removed. Photodynamic Diagnosis (PDD) of bladder cancer, or fluorescence cystoscopy, assists in the diagnosis and treatment of non muscle invasive bladder cancer by helping to identify tumour that may otherwise have been missed using conventional white light cystoscopy.
PDD allows a more thorough resection which results in less risk of leaving residual tumour, leading to a reduction of tumour seen during follow-up. Use of this technology has the potential to reduce 2,116 bed days over a five year period, thus reducing the number of follow-up invasive procedures required for certain patients. A more complete visualisation of tumour may also enable identification of disease at higher risk of recurrence or progression. This could enable more appropriate and timely treatment resulting in earlier placement of patients onto a more appropriate 'high risk' management pathway before the disease progresses. This is particularly pertinent where carcinoma in situ is present.
This technology may play an important role in reducing overall morbidity and hospital length of stay for patients and can play a significant role in ensuring that diagnostic services throughout the NHS are more productive whilst removing the risk in extra procedures that a delay in diagnosis can bring. Delayed Diagnosis of Cancer in England (published by National Patient Safety Agency), recently reported that whilst cancer mortality in people under the age of 75 years fell by over 17% between 1996 and 2005, further progress is required to surpass the European standards. It is generally agreed that later diagnosis has been a major factor in the poorer survival rates in England compared with other countries in Northern and Western Europe (Cancer Reform Strategy, 2010).
Key Benefits of the Technology
- A reduction in hospital admissions for certain patients. Improved diagnosis and subsequent treatment plans for primary bladder cancer patients.
- Reduction in overall length of stay. By providing an enhanced diagnostic service and eliminating the need for a second operation for certain patients, subsequent length of stay is lowered by approximately 2,116 bed days over a five year period.
- Delivery of the 31 and 62 day cancer treatment targets. This technology has the potential to reduce recurrent rates and the need for subsequent procedures. This may increase service capacity and enable Trusts to deliver cancer treatment targets.
- Improved efficiency for the NHS. Being able to move to adjuvant therapies straight after initial surgery ensures that a more enhanced service is introduced.
- Improved quality of life. Removing the number of hospital visits and subsequent procedures provides an improved quality of life for patients and their families over the follow up period.
- Higher quality services and support for patients. A systematic approach to implementation will deliver an enhanced clinical service and will allow appropriate therapies to start straight away.
- Long term savings to the NHS. This is achieved through a reduction in subsequent demands on health service expenditure as a result of further surgical procedures.
Click to be taken to the Benefits 'vs' Barriers section of this How to Why to Guide. This will compare some of the perceived adoption barriers within the organisation and how they may hinder uptake of this technology.
Impact on Key Policy Areas
The use of photodynamic diagnosis of bladder cancer (PDD) is signposted by the Map of Medicine, the European Association of Urology, the Scottish Intercollegiate Guidelines Network and the British Association of Urological Surgeons. The availability of an enhanced diagnostic technique which is concurrent with transurethral resection of bladder tumour (TURBT) offers the potential to save up to 2,116 bed days across the NHS over a five year period (this will vary depending on local protocols). This saving would also remove the inefficiencies associated with unnecessary follow-up protocol post-operatively.
The impact of under-diagnosed bladder cancer on those patients who could otherwise benefit from a single operation has the potential to be a huge burden on the health economy. The benefits associated with avoiding a second surgical procedure including a more thorough resection with less risk of leaving residual tumour and therefore a reduction of tumour seen during follow-up. Reducing the number of invasive procedures for certain patients can reduce overall activity levels and release NHS resources at both a local and national level.
The Policy section of this How to Why to Guide discusses policy in more detail and hosts an array of documentation and supporting resources for Trusts surrounding these areas that you may find helpful.
Summary of Clinical Evidence
The National Institute for Health and Clinical Excellence (NICE) completed a Health Technology Assessment on the PDD technology in January 2010 which found that photodynamic diagnosis has higher sensitivity but lower specificity than white light cystoscopy and cytology, respectively in detecting bladder cancer. Diagnostic strategies involving photodynamic diagnosis provide additional benefits in terms of more complete tumour removal at initial surgery (TURBT) with a subsequent reduction in later cancer recurrence at a cost that society might be willing to pay.
Click to be taken to the Evidence Base section of this How to Why to Guide, which will explain the evidence base behind the technique in more detail.
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