BladderPath data support MRI use before TURBT in MIBC

Results from the phase 2/3 BladderPath trial (ISRCTN 35296862) indicate that incorporating multiparametric MRI (mpMRI) prior to transurethral resection of the bladder tumor (TURBT) in patient with suspected muscle-invasive bladder cancer (MIBC) improves bladder cancer-specific survival.¹

“We know that the bladder cancer diagnostic and treatment pathway is often very prolonged. There's a lot of to-ing and fro-ing between cystoscopies and so on, and it's been pretty much unchanged apart from the development of flexible cystoscopy for the last century. We also know that…because of these multiple steps: cystoscopy here, maybe chemotherapy in another center, surgery in another center, radiotherapy in another center, that patients often take a long time to get to the actual treatment, typically over 100 days. This is true in North America; it's true in Europe. And despite all the massive improvements we're seeing in treatment for metastatic disease, broadly, the outcome for patients with bladder cancer have been unchanged for 30 years, and also for most other sites, imaging and biopsy is a standard of care, not debulking,” said Nicholas D. James, MD, PhD, Professor of Prostate and Bladder Cancer Research at the Institute of Cancer Research and the Royal Marsden Hospital in London during his presentation of the data at the 2025 European Society for Medical Oncology Congress in Berlin, Germany.

The open-label, multi-stage, randomized controlled BladderPath trial sought to evaluate whether introducing mpMRI prior to TURBT would reduce the time radical treatment in patients with suspected MIBC. Patients were randomly assigned to TURBT (pathway 1) or mpMRI before TURBT (pathway 2).

Previously reported research elucidated the feasibility stage² and intermediate stage of BladderPath.³ At ESMO 2025, James presented PFS and OS from the final stage, which he noted was underpowered as the investigators had to halt recruitment during the COVID-19 pandemic and were unable to restart the process.

A total of 7 patients following pathway 1 died of non-bladder cancer causes, including COVID-19 (2 patients), cardio-respiratory complications (1 patient), upper aero-digestive tract cancer (3 patients), and other cancer (1 patient). Nine patients following pathway 2 died of non-bladder cancer causes, including COVID-19 (1 patient), cardio-respiratory complications (3 patients), upper aero-digestive tract cancer (3 patients), and other cancer (1 patient). Thirteen patients following pathway 1 and 7 patients following pathway 2 died of bladder cancer.

The HR for PFS was 0.75 (95% CI: 0.46-1.22, P = .0249). The HR for bladder cancer-specific survival was 0.36 (95% CI: 0.135-0.98, P = .046).

“If we break that down by non-invasive and invasive, we can see a very clear and obvious and early separation in muscle-invasive bladder cancer survival in favor of the MRI pathway. And I think you'll agree that's quite a striking separation,” James commented.

The HR for OS was 0.67 (95% CI: 0.34-1.33, P = 0.252).

“In conclusion, we've got a strong trend to improvement in all the key trial metrics: progression-free, overall and, very importantly, bladder cancer-specific survival. Also very importantly, because when we presented this previously, there [was] concern that we were treating patients on the wrong pathway, [that we] would be misdiagnosing them on an MRI-based pathway compared to a TURBT-based pathway, and that might compromise the outcomes. There is no evidence we're doing that. And finally, there's a statistically significant improvement in bladder cancer specific-survival on the MRI-guided pathway, which we think is potentially very important indeed,” James said.

REFERENCES

1. James ND, Pirrie S, Liu W, et al. Randomized comparison of upfront magnetic resonance imaging versus transurethral resection for staging new bladder cancers: Final survival analysis from the BladderPath trial. Presented at: European Society for Medical Oncology Congress. October 17-21, 2025. Berlin, Germany. Abstract LBA111. https://s3.eu-central-1.amazonaws.com/m-anage.com.storage.esmo/static/esmo2025_abstracts/LBA111.html.pdf

2. Comparing an imaging-guided pathway with the standard pathway for staging muscle-invasive bladder cancer: Preliminary data from the BladderPath study. Eur Urol. 2021;80(1):12-15. doi:10.1016/j.eururo.2021.02.021

3. 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;43(12):1417-1428. doi:10.1200/JCO.23.02398