The aim of the retreat was to develop consensus statements on two disease processes.
First, the group sought to define optimal sequencing of therapy in muscle-invasive bladder cancer. Several phase 3 trials with perioperative immunotherapy offer an opportunity for a paradigm change in both cisplatin-eligible and-ineligible patients. Given the increasing interest in bladder preservation, there was debate surrounding how best to define clinical complete response. However, the group agreed that the current curative intent treatment of muscle-invasive bladder cancer (MIBC) includes either radical cystectomy or trimodal therapy (TMT).
Emerging markers of response to therapy, including circulating tumor DNA (ctDNA) and multi-parametric MRI using the VI-RADS scale, show promise and may aid in patient selection for bladder sparing and adjuvant therapy moving forward.
In the locally advanced or metastatic setting, there was consensus that enfortumab vedotin plus pembrolizumab, when available, should represent the preferred treatment choice. The nuances and challenges of managing patients with oligometastatic disease were also addressed, highlighting the opportunity for cure in select patients. However, the optimal treatment modality and timing of treatment remains undefined.
Additional topics in the session included:
- Trial design endpoints for neoadjuvant/adjuvant therapy
- Biomarkers for patient selection for neoadjuvant/adjuvant therapay or surgery alone
- The multi-disciplinary management of metastatic disease.
Currently, cystoscopic surveillance remains the standard of care for follow-up of patients with IR NMIBC, as no urinary biomarkers have achieved the required sensitivity or specificity to serve as a replacement. There is ongoing debate regarding the optimal length and intensity of surveillance schedules. The group explored strategies for de-intensification of surveillance and treatment in order to reduce the need for multiple TURBTs.
Regarding trials of IR NMIBC agents, whilst treatment efficacy is essential, length and duration of follow-up are equally important, as is quality of life. Given that IR NMIBC is not lethal, there was broad consensus that trial design should be patient-centered and include validated quality of life questionnaires.
Patient advocates from the Bladder Cancer Advocacy Network (BCAN) and the World Bladder Cancer Patient Coalition (WBCPC) concluded the working group presentations by providing valuable insights, highlighting the need to eliminate restrictive eligibility criteria in clinical trials. Age should not be a barrier, as excluding older patients solely based on age may deny them effective treatments they might tolerate well if otherwise fit. Advocate groups also emphasised the importance of addressing survivorship challenges in IR NMIBC. Notably, the discontinuation of surveillance cystoscopies can induce significant patient anxiety, as many seek reassurance from continued specialist care.
In this context, shared decision-making is crucial for discussing patients’ ongoing needs and preferences for care over time.
The retreat utilized a process of literature review, expert opinion-based recommendations synthesis, and pre-meeting voting by IBCG members. Recommendations were revised based on discussion, and final statements underwent live voting at the conclusion of the meeting, with ratification of statements achieving consensus. The resulting publications on both the optimal sequencing of therapy in MIBC and IR NMIBC are forthcoming.
Written by:
- Kelly Bree, MD, Urologic Oncologist, MD Anderson Cancer Center, Houston, TX
- Niyati Lobo, MD, Consultant Urological Surgeon, Cambridge University Hospital, UK