Incorporating mpMRI in bladder cancer staging may improve time to treatment

Adding multiparametric magnetic resonance imaging (mpMRI) into the initial staging pathway for muscle-invasive bladder cancer (MIBC) can expedite the time to definitive treatment, according to findings from the BladderPath trial, which were published in the Journal of Clinical Oncology.¹

According to the authors, this study demonstrates that TURBT may be safely omitted in select patients.

“Bladder cancer is a common cancer and we know that with any cancer, and especially muscle-invasive bladder cancer, speed is of the essence when treating. Any ways to improve the time from initially suspecting cancer to getting the right treatment gives patients the best chance of responding well,” explained lead author Richard T. Bryan, PhD, professor in urothelial cancer research and director of the bladder cancer research centre at the University of Birmingham, in a news release on the findings.² “However, this aspect of the bladder cancer care pathway has remained essentially unchanged worldwide for over 100 years, whilst the rest of medicine and health care has innovated around it. We wanted to evaluate whether the 21st century approaches that have benefited the diagnosis and treatment of all other cancer patients would also benefit bladder cancer patients. The BladderPath trial looked at whether adding in some extra or alternative diagnostic testing, mpMRI first [and then] biopsy or TURBT, could speed up the time taken to receive the correct treatment for the most concerning form of bladder cancer.”

In total, the trial included 143 participants with suspected new bladder cancer across 17 hospitals in the UK. Participants were randomly assigned 1:1 to undergo initial transurethral resection of the bladder tumor (TURBT; pathway 1; n = 72) or to initial mpMRI (pathway 2; n = 71). Those in pathway 2 underwent TURBT if they were determined, per visual assessment, to have probable non-muscle invasive bladder cancer (NMIBC) or to undergo mpMRI for possible MIBC.

According to the authors, “If the proportion of participants with possible MIBC randomly assigned to Pathway 2 who correctly followed pathway protocol exceeded 80%, Pathway 2 would be considered feasible in clinical practice.”

Overall, 92% of patients (36 of 39) with possible MIBC in pathway 2 underwent mpMRI. Of those, 92% (n = 33) were fully compliant with the VI-RADS protocol and 94% (n = 34) demonstrated optimal bladder filling. Across both arms, the proportion of patients who correctly followed their respective protocol was 96%.

At the time of data report, 91% of patients received the correct treatment. This included 50 patients in the TURBT arm and 53 patients in the mpMRI arm who were found to have NMIBC, and 15 patients in the TURBT arm and 14 patients in the mpMRI arm who were found to have MIBC. Among those who did not receive the correct treatment, 2 participants with probable NMIBC were diagnosed with MIBC after TURBT and 4 participants with probable NMIBC were unconfirmed as MIBC/NMIBC.

In total, there were 26 patients assessed as possible MIBC who were confirmed to have MIBC, comprised of 14 patients in the TURBT arm and 12 in the mpMRI arm. Of those, 25 received the correct treatment. The median time to correct treatment (TTCT) for these patients was 77 days across both arms.

When stratified by pathway, the median TTCT was 98 days (95% CI, 72 to 125) among those who underwent initial TURBT and 53 days (95% CI, 20 to 89) among those who underwent initial mpMRI. The mpMRI pathway demonstrated a favorable TTCT on a model adjusting for sex and age, and with study center as a random effect (HR, 2.9; 95% CI, 1.0 to 8.1; P = .02).

The investigators also assessed TTCT among the 58 participants with probable NMIBC who were confirmed to have NMIBC. This included 28 patients in the TURBT arm and 30 patients in the mpMRI arm who all received TURBT as correct treatment. The median TTCT among all participants was 16 days (95% CI, 11 to 23).

There was no difference in TTCT between the 2 study arms. The median TTCT was 14 days (95% CI, 10 to 29) among participants in the TURBT arm and 17 days (95% CI, 8 to 25) among patients in the mpMRI arm (HR, 0.8; 95% CI, 0.5 to 1.5).

According to the authors, this finding provides “no evidence that shorter TTCT for participants with MIBC was achieved to the detriment of TTCT for participants with NMIBC.”

They added, "This is impressive, given some participants with mpMRI-staged MIBC still underwent TURBT for histologic clarification."

When looking at all participants in the study, the median TTCT was 31 days (95% CI, 22 to 37). The mpMRI pathway was shown to have a faster TTCT, with a median TTCT of 25 days (95% CI, 18 to 35) vs 37 days (95% CI, 22 to 37) among patients in the TURBT arm (P = .03). When adjusting for age and sex, the model favored pathway 2 (HR, 1.4; 95% CI, 0.9 to 2.0).

“This research shows that by adding an MRI pre-biopsy we can cut the time taken to correct treatment for the worst bladder tumors—those that invade the bladder muscle wall—by almost half, from 98 days down to 53 days,” concluded chief investigator of the trial, Nicholas D. James, PhD, in the news release.² “We’ve also shown that around 1 in 7 of these patients with problematic tumors can avoid the surgical procedure used to diagnose bladder cancer. As an MRI is considerably cheaper than this surgery, we estimate that this new diagnostic pathway will save money, as well as saving surgical theatre space and preventing patients from undergoing unnecessary procedures. The next step for this research is to assess whether this impacts the survival of these patients.”

References

1. Bryan RT, Liu W, Pirrie SJ, et al. Randomized comparison of magnetic resonance imaging versus transurethral resection for staging new bladder cancers: Results from the prospective BladderPath trial. J Clin Oncol. 2025:JCO2302398. doi:10.1200/JCO.23.02398

2. MRI scanning and biopsy could reduce delays in the correct treatment for bladder cancer by more than six weeks. News release. University of Birmingham. January 15, 2025. Accessed January 21, 2025. https://www.birmingham.ac.uk/news/2025/mri-scanning-and-biopsy-could-cut-time-to-correct-bladder-cancer-for-by-more-than-six-weeks