Bladder Cancer Coverage from Every Angle

Nicholas D. James, MB, PhD, on Bladder Cancer: MRI and Biopsy vs Resection for Cystoscopic Staging

Posted: Thursday, September 15, 2022

Nicholas D. James, MB, PhD, of London’s Institute of Cancer Research, discusses initial results from BladderPath, a study that compared MRI and biopsy vs surgical resection for diagnosis and staging of suspected muscle-invasive bladder cancer. The findings suggest that use of the image-guided pathway may halve the time to treatment with no apparent adverse effect on outcomes for patients with non–muscle-invasive disease.


Disclaimer: This video transcript has not been proofread or edited and may contain errors.

I've just presented the BladderPath trial data here at ESMO. So the diagnostic pathways for bladder cancer have been completely unchanged for a century. So if you've got suspected bladder cancer, the standard practice now as it was a hundred years ago, is that you have a rigid endoscopy under general anesthetic and a piecemeal resection of the bladder tumor, essentially using a hot wire to slice the tumor out in bits. The surgeon keeps cutting away until they've cut away as much as they can. The idea is that you can assess A, that it's cancer or not, but that's not usually in doubt, and secondly, whether the cancer is invading into muscle or not. Now, the problem with this as a diagnostic pathway is that it often gets it wrong. So the resections are often incomplete, there's no muscle or you don't get the right bit of muscle so you don't know whether the tumor is going into the muscle or not. It often has to be repeated. The second problem with it is that if you put contrast medium in the bladder, after this is done, if they've had a complete resection, that around 50% of cases will have contrast going into the extra recycle space. So this is urine containing tumor cells so this is probably a very harmful thing. Around one in 20 cases you will have an overt perforation of the bladder. So it's quite a morbid procedure and it also builds a lot of delay and you have to recover from it. You often have to repeat it to get accurate staging. So there's good data now with MRI showing that it's both more sensitive and more specific in terms of assessing the stage of bladder cancer. So we set out to test the proposition that for patients with suspected muscle invasive bladder cancer at flexible cystoscopy in the hematuria clinic, we would randomize them to MRI scan and at a biopsy only versus the endoscopic TURBT trans-urethral resection of the bladder tumor. So we had two stages to the trial. We had a feasibility stage, can we just shoehorn this into the pathway? And we did it multi-center across a number of centers in the UK. The target was 80% got the right pathway. We actually hit well over 90%. So it meant we had enough patients with scans that we were adequately testing the pathway. Then the second end point was, could we reduce the time to correct treatment? So the muscle invasive tumors, we defined the correct treatment as surgery, radiotherapy, chemotherapy, or palliative care. For non-invasive tumors, the correct treatment was a trans-urethral resection. So for those patients, we had potentially delayed that by doing a scan instead of the TURBT. What we found was that for the primary outcome measure, time to treatment for the muscle invasive tumors, the median time came down from 98 days on the control arm, which is what we expected it would be from pre-trial assessments of NHS data, came down to 53 days. So we pretty much halved the time to treatment and we halved it for all of the treatment modalities, surgery, radiotherapy, chemotherapy, palliative care. They all got faster. The secondary endpoint was what do we do to the time to TURBT for the patients with non-muscle invasive tumors, because we wanted to make sure we weren't making one group better at the expense of the others. It turned out that that got faster as well. We think what happened was that if you had a patient who had a nasty looking tumor you thought might have been muscle invasive, turned out to be non-muscle invasive, those got fast tracked. So overall, our conclusion was that the image-directed pathway was faster. You made better decisions and you made better decisions across the whole range. The non-invasive right the way through to the advanced patients getting palliative care got faster decisions. We could find no evidence either that we, for example, doing inappropriate cystectomies on patients who turned out not to have muscle invasive disease. We know that MRI is accurate and so it was proven here as well. So we think this provides very powerful evidence for quite radically rethinking the way that we manage muscle invasive bladder cancers in terms of the diagnostic pathway because these patients often take a long time to get to the correct definitive treatment because of multiple hands off in the standard pathway.

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