NIAGARA in the EV + IO Era / MIBC 07/31/2026

Ep. 4: Personalizing Perioperative Treatment for Muscle-Invasive Bladder Cancer With NIAGARA and EV-Based Regimens

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

  • Patient comorbidities, anticipated toxicities, and histologic subtype should guide perioperative treatment selection in the absence of validated predictive biomarkers.
  • Experts cautioned against cross-trial comparisons between NIAGARA and enfortumab vedotin (EV)–based studies.
  • Radical cystectomy remains a critical component of curative-intent therapy, with multidisciplinary care and shared decision-making central to treatment planning.

In this Clinical Insights discussion, Ashish M. Kamat, MD, MBBS, FACS, of The University of Texas MD Anderson Cancer Center, moderated a panel featuring 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.

The panel agreed that treatment selection should extend beyond efficacy data alone. Although no validated biomarker currently identifies which patients should receive durvalumab plus gemcitabine/cisplatin versus EV plus pembrolizumab, baseline comorbidities often help guide decision-making. The experts discussed tailoring therapy according to anticipated toxicities, including renal impairment, cardiovascular disease, diabetes, peripheral neuropathy, dermatologic conditions, and hepatic dysfunction. 

Histologic subtype also remains an important consideration. Although patients with urothelial carcinoma containing squamous differentiation generally continue to be candidates for platinum-based therapy, pure squamous cell carcinoma, adenocarcinoma, and small cell carcinoma require different strategies. 

Managing treatment-related toxicity without compromising definitive surgery was another major focus. Dr. Aggen noted that early recognition and proactive management of adverse events are essential to maintaining therapy and avoiding unnecessary delays to radical cystectomy. The panel suggested that patients experiencing inadequate clinical response or persistent symptoms during neoadjuvant therapy may warrant earlier imaging and reassessment, although current evidence does not support routine switching between perioperative regimens. 

In closing, the panel emphasized that the growing number of evidence-based perioperative options has made multidisciplinary collaboration and shared decision-making more important than ever. As interest in biomarker-guided bladder preservation grows, current level 1 evidence continues to support radical cystectomy as an integral component of curative-intent therapy. Until predictive biomarkers and additional prospective data become available, clinicians should avoid cross-trial comparisons between NIAGARA and EV-based studies. Instead treatment should be based on patient characteristics, toxicity profiles, and informed discussions regarding available therapeutic options.