HOUSTON — Bladder cancer, recently designated as a presumptive condition for Gulf War and Post-9/11 veterans, per the PACT Act, is the third most prevalent noncutaneous cancer among veterans, following prostate and lung cancer. As a result, it presents a significant healthcare challenge for the VA system.
While clinical guidelines for bladder cancer management offer evidence-based recommendations for many aspects of care, some areas remain ambiguous, leading to variations in treatment approaches, said Jeffrey Jones, MD, chief of urology in the Operative Care Line at the Michael E. DeBakey Veteran Affairs Medical Center. In a recent paper published in Current Oncology, Jones, Jennifer Taylor, MD, and their team explored how unique factors related to veterans and the VA system influence bladder cancer care. They also emphasized the importance of consistent equipment allocation and the adoption of advanced technology—particularly blue light cystoscopy (BLC) with hexaminolevulinate (HAL)—to enhance patient outcomes, reduce costs and standardize care across the VA system.1
VAMCs face distinct challenges due to system capacity and patient characteristics, including exposure to harmful substances and complex comorbidities. Veterans deployed to Iraq or Afghanistan with combat exposure are more likely to start or resume smoking—a known risk factor for bladder cancer. Additionally, exposure to chemicals like Agent Orange and Agent Blue during military service has been linked to bladder cancer.
Veterans also tend to have a higher comorbidity index, increasing the risks associated with anesthesia and surgery. “They have more severe health issues, so it’s crucial to ensure that any procedure requiring anesthesia is absolutely necessary and that the patient is optimized for surgery,” Jones noted.
These patient and system-related factors influence decisions about diagnosis and disease management, including the selection of imaging tests, chemotherapeutic agents and surgical options.
Examples cited in the paper include:
Imaging Alternatives: Balancing Accuracy and Safety
Although CT urography (CTU) is considered the gold standard for imaging in hematuria evaluation, its use is often limited among veterans due to renal insufficiency and a risk of contrast-induced kidney injury, especially for those with chronic kidney disease, diabetes or heart failure. Additionally, CT scans are expensive, expose the patient to radiation and have suboptimal yield for detecting urothelial malignancy.
To address these challenges, many VA centers are incorporating ultrasonography into the hematuria evaluation algorithm, as it is less invasive, avoids radiation exposure and is safer for patients with renal impairment. It also offers significant cost savings with reasonable diagnostic accuracy, making it a practical alternative to CTU.
Managing Asymptomatic Microhematuria (AMH)
AMH, characterized by at least three red blood cells per high-powered field (hpf) without an infection, is the most common initial symptom of bladder cancer. Despite its prevalence—occurring in 9-18% of healthy individuals—only 2.6% of AMH cases are linked to cancer. This low diagnostic yield has raised concerns about the efficiency of comprehensive workups for all AMH patients at the current 3 RBCs/hpf guideline threshold.
The 2020 American Urological Association guidelines now recommend risk stratification based on age, smoking history and comorbidities. Low-risk patients may undergo repeat urinalysis or noninvasive imaging, while high-risk patients require more thorough evaluations, including cystoscopy and CT urography. However, despite these updates, clinical practice remains inconsistent.
Addressing BCG Shortages With Alternative Immunotherapy
Adjuvant intravesical immunotherapy with bacillus Calmette–Guérin (BCG) is a standard treatment for high-grade and carcinoma in situ (CIS) non-muscle-invasive bladder cancer (NMIBC). For intermediate-risk NMIBC, the American Urological Association (AUA) recommends maintenance therapy with chemotherapy or immunotherapy, reserving BCG for high-risk cases. However, BCG shortages pose significant challenges, particularly for VA patients who may have a lower tolerance for side effects and limited access to the drug.
Gemcitabine has emerged as a viable alternative due to its lower cost and fewer side effects compared to BCG or Mitomycin C. It is also effective in reducing recurrence, particularly in cases of BCG failure. During shortages, the AUA suggests prioritizing BCG for high-risk patients, considering reduced doses, or using alternative treatments such as gemcitabine with docetaxel.
Blue Light Cystoscopy (BLC) With HAL: Enhancing Detection and Reducing Reoperations
For patients with high-risk bladder cancer, clinical guidelines recommend repeat resection following an initial transurethral resection of bladder tumor (TURBT). However, the frailty of the veteran population and the limitations in operating room availability can make a timely second procedure challenging.
BLC with HAL offers enhancements to bladder cancer detection and improving the thoroughness of tumor resection compared to standard white-light cystoscopy, the standard illumination. This technology enables the identification of smaller, less conspicuous lesions, allowing for earlier intervention and potentially better outcomes.
“The biggest driver for putting the white paper together was that we wanted to make sure every VA had the rationale for why they needed state-of-the-art techniques for diagnosing and treating bladder cancer,” Jones told U.S. Medicine. “The blue light detection system allows you to find smaller and less visible bladder cancer lesions than does WLC. Thus, you can find cancers earlier and treat them more completely, thereby resulting in better outcomes.”
At the Michael E. DeBakey VA Medical Center, BLC has been integrated into clinic diagnostic cystoscopies and weekly preoperative discussions to determine its use during OR TURBT procedures, anesthesia requirements and imaging needs. The center also has standardized sterile practices and flexible cystoscopy setups, allowing for up to eight BL cystoscopies daily.
Since the report was published, several VA centers have used the white paper to justify acquiring BLC systems, Jones noted. “And that’s the biggest impact that we could have—to make sure that state-of-the-art technology was available for our veterans.”
“By ensuring that every veteran has access to cutting-edge diagnostic and treatment technologies, the VA can continue to improve bladder cancer care and outcomes,” he said.
- Taylor J, Patel S, Gaitonde K, Greene K, et al. The Management of Non-Muscle-Invasive Bladder Cancer in a Veteran Patient Population: Issues and Recommendations. Curr Oncol. 2024 Oct 28;31(11):6686-6698. doi: 10.3390/curroncol31110493. PMID: 39590124; PMCID: PMC11592542.
