Ep. 4: Multidisciplinary Approaches to Emerging Bladder Cancer Treatments
Key Points
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For muscle-invasive bladder cancer (MIBC), perioperative systemic therapy—gemcitabine-cisplatin plus durvalumab or enfortumab vedotin plus pembrolizumab (EV-pembrolizumab)—improves outcomes without compromising surgical feasibility. However, careful toxicity management is essential.
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Treatment personalization using biomarkers, pathologic response, and cisplatin eligibility can help tailor therapy and guide decisions on adjuvant cycles or therapy sequencing.
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For non–muscle-invasive bladder cancer (NMIBC), combining BCG with checkpoint inhibitors such as durvalumab or with cisplatin-based subcutaneous immunotherapy (IO) shows promise in high-risk patients, with a multidisciplinary approach critical for monitoring and managing long-term toxicities.
Advances in Perioperative Therapy for Muscle-Invasive Bladder Cancer
A recent Clinical Insights discussion held at an event coinciding with the 2026 American Society of Clinical Oncology Genitourinary (ASCO GU) Cancers Symposium highlighted the evolving treatment landscape for muscle-invasive and non–muscle-invasive bladder cancer. Moderated by Rahul Gosain, MD, MBA, of the Wilmot Cancer Institute, and Rohit Gosain, MD, of Roswell Park Comprehensive Cancer Center, the panel included Sia Daneshmand, MD, of the Keck School of Medicine of USC; Matt Galsky, MD, of Mount Sinai; Shilpa Gupta, MD, of Cleveland Clinic; and Chad Reichard, MD, of Urology of Indiana.
Discussion focused on emerging perioperative systemic therapies for MIBC, including the FDA-approved gemcitabine-cisplatin plus durvalumab regimen and EV-pembrolizumab. These therapies improve local and micrometastatic control and allow patients to proceed safely to radical cystectomy. Data from trials such as NIAGARA and KEYNOTE-B15 show meaningful improvements in event-free survival and pathologic complete response rates.
Expanding Roles in Non–Muscle-Invasive Bladder Cancer
Shifting focus to high-risk NMIBC, panelists discussed promising results from BCG plus checkpoint inhibitor trials, such as CREST and POTOMAC, using subcutaneous durvalumab or cisplatin-based IO. These trials demonstrated improved outcomes compared with BCG alone, particularly for patients with high-grade T1 disease with or without carcinoma in situ, multifocal lesions, or variant histologies.
Managing long-term immune-related toxicities remains a key consideration; up to 15% of patients may experience lasting effects such as hypothyroidism requiring lifelong replacement therapy. Community urologists often lead therapy initiation, but coordination with medical oncology ensures effective monitoring and management of potential serious adverse events, such as myocarditis or other immune-mediated complications. Both trial regimens showed comparable efficacy, though treatment duration varied (1 vs 2 years), reinforcing the need for individualized patient selection and shared decision-making.