NIAGARA in the EV + IO Era / MIBC 07/30/2026

Ep. 3: Selecting Perioperative Therapy for Muscle-Invasive Bladder Cancer Based on Patient and Tumor Characteristics

Professional portrait of a smiling man in a suit and tie, wearing glasses, against a white background, suitable for medical or healthcare-related content. Ashish M. Kamat, MD, MBBS, FACS Professional portrait of a man in a dark suit and blue tie, smiling confidently against a neutral background. David H. Aggen, MD, PhD Professional portrait of a female oncologist in a white lab coat, smiling confidently, representing expertise in cancer treatment and research. Alexandra Drakaki, MD, PhD Comprehensive cancer research updates and oncology news from OncUpdates to stay informed on latest treatments, clinical trials, and breakthroughs in cancer care. Raji Shameem, MD

Key Points

  • Perioperative therapy selection for muscle-invasive bladder cancer (MIBC) should be individualized based on comorbidities, treatment-related toxicities, cisplatin eligibility, and patient preferences rather than a single preferred regimen.
  • Histologic subtype remains an important consideration, although prospective data guiding regimen selection across variant histologies remain limited.
  • The panel emphasized that radical cystectomy continues to be the standard component of curative-intent treatment despite growing interest in bladder-preservation strategies.

The growing number of FDA-approved perioperative treatment options for MIBC has shifted clinical discussions from whether to administer systemic therapy to determining which regimen is most appropriate for an individual patient. During this segment of a recent Clinical Insights discussion, Ashish M. Kamat, MD, MBBS, FACS, of The University of Texas MD Anderson Cancer Center, was joined by David H. Aggen, MD, PhD, of Memorial Sloan Kettering Cancer Center; Alexandra Drakaki, MD, PhD, of the University of California, Los Angeles; and Raji Shameem, MD, of Orlando Health, to examine practical considerations for treatment selection, including patient comorbidities, toxicity profiles, and histologic subtype.

Discussing treatment selection in the community setting, Dr. Shameem emphasized that there is no single preferred perioperative regimen. Instead, clinicians should carefully evaluate baseline characteristics such as renal function, cardiovascular disease, diabetes, dermatologic conditions, and overall treatment tolerance. The panel agreed that the availability of multiple evidence-based perioperative regimens allows clinicians to better tailor treatment to each patient’s clinical profile.

The experts also revisited the ongoing debate surrounding bladder preservation following neoadjuvant therapy. Although high pathologic complete response rates have generated enthusiasm for surveillance strategies, the panel cautioned that current evidence does not support omitting radical cystectomy outside of clinical trials. Dr. Aggen noted that biomarker-driven approaches may eventually identify patients who can safely avoid surgery, but existing studies have not yet established reliable criteria. The speakers agreed that, until prospective data mature, radical cystectomy remains an essential part of curative-intent treatment following systemic therapy.

The segment concluded with a discussion of the role of histologic subtype in therapeutic decision-making. Dr. Aggen explained that prospective evidence remains limited for variant histologies, making patient-specific assessment particularly important. The panel also highlighted emerging biologic insights regarding nectin-4 expression across histologic subtypes that may ultimately help refine selection between antibody-drug conjugate–based and platinum-based perioperative regimens.