Bladder cancer is the most frequently occurring tumour of the urinary system.  Although many early bladder cancers are readily treatable with transurethral resection of bladder tumour (TURBT) it remains one of the most costly cancers to manage on a per patient basis because of its high prevalence, high recurrence rate, need for adjuvant treatments and the requirement for long-term cystoscopic surveillance. The total cost of treatment and 5-year follow-up of patients with Non Muscle Invasive Bladder Cancer (NMIBC) diagnosed during 2001–02 in the United Kingdom was £64 million.  From a patient perspective, there often are considerable anxieties about recurrences, surgery and progression requiring additional therapies with potential mortality and long term morbidity (e.g. radical surgery).  More efficient management strategies to reduce NMIBC recurrence and hence decrease both the burden to patients and costs to the NHS are urgently needed.

PHOTO was a multicentre randomised controlled phase III trial funded by the NIHR HTA Programme.

The PHOTO trial sought to determine the efficacy of using photo-dynamic diagnosis (PDD) guided by a fluorescent tumour marker under blue light, instead of conventional white light, for TURBT in intermediate and high risk non-muscle invasive bladder cancer, and whether its implementation was worthwhile for the NHS.

The primary clinical outcome was time to recurrence, for each of the two treatment strategies, with a principal point of interest at 3 years.

In total, 538 participants were enrolled from 22 participating UK hospital sites.  After a median of 44 months follow-up, 86 of 209 in the PDD group and 84 of 217 in the WL had recurrences.  The hazard radio for recurrence was 0.94 (95% CI 0.69 to 1.28, p=0.70).  PDD guided TURBT was more costly than WL directed TURBT over a 3 year follow-up, with no evidence in difference in quality adjusted life years.  The study concluded that PDD-guided TURBT did not reduce recurrence rates and was not cost-effective compared with WL-guided TURBT at 3 years. 

The PHOTO trial was funded by the NIHR HTA programme (11/142/02) and was led by Professor Rakesh Heer who was based at the University of Newcastle.  The trial was managed by CHaRT in collaboration with the Institute of Cancer Research Clinical Trials Unit. 





Tandogdu Z, Lewis R, Duncan A, et al. Photodynamic versus white light-guided treatment of non-muscle invasive bladder cancer: a study protocol for a randomised trial of clinical and cost effectiveness. BMJ Open 2019;9:e022268. doi:10.1136/bmjopen-2018-022268

Heer R, Lewis R, Duncan A, Penegar S, Vadiveloo T, Clark E, et al. Photodynamic versus white-light-guided resection of first-diagnosis non-muscle-invasive bladder cancer: PHOTO RCT. Health Technol Assess 2022;26(40)

Heer R, Lewis R, Vadiveloo T, et al. A Randomized Trial of PHOTOdynamic Surgery in Non–Muscle-Invasive Bladder Cancer. NEJM Evid 2022; 1 (10).  DOI: 10.1056/EVIDoa2200092

Yu G, Rice S, Heer R, et al.  Photodynamic Diagnosis-guided Transurethral Resection of Bladder Tumour in Participants with a First Suspected Diagnosis of Intermediate- or High-risk Non–muscle-invasive Bladder Cancer: Cost-effectiveness Analysis Alongside a Randomised Controlled Trial. European Urology Open Science, Volume 53, 2023, Pages 67-77.