Defining High-Risk NMIBC and Diagnostic Gaps Before Referral

In this Urology Times Special Report series, Mark D. Tyson II, MD, MPH discusses high-risk non–muscle invasive bladder cancer (NMIBC) with Alexandra Drakaki, MD.

Tyson opens the program by introducing Drakaki and framing the discussion around how academic centers coordinate high-risk NMIBC care and how that model might translate to community practice. Drakaki emphasizes that the relationship between urology and medical oncology is central to identifying and managing these patients well.

Asked how high-risk NMIBC is currently defined, Tyson walks through the landscape of guidelines urologists draw on, including the American Urological Association (AUA), European Association of Urology (EAU), National Comprehensive Cancer Network, and the International Bladder Cancer Group, but says most clinicians start pragmatically by asking whether cystectomy is indicated upfront. He describes the EAU's "very high risk" category, which includes high-volume T1 disease, concomitant carcinoma in situ, lymphovascular invasion, variant histology, or extravesical disease such as involvement of the prostatic urethra or distal ureter, noting many of these patients are surgical candidates from the outset. For patients who don't clearly need immediate cystectomy, he stratifies more closely along AUA guideline lines. On diagnostic gaps, he notes that patients often arrive from community practice without a clear picture of their bladder status, prompting a repeat transurethral resection of the bladder tumor to confirm adequate muscle sampling and complete resection, sometimes with blue light cystoscopy to catch satellite lesions, along with updated upper-tract imaging and consideration of emerging biomarkers.

Turning the question to Drakaki, Tyson asks what unmet needs she sees once a high-risk, BCG-naive NMIBC patient reaches her practice. She points to the POTOMAC trial (NCT03528694) and other ongoing studies incorporating systemic therapy into local disease management, noting that until recently, the timing of when systemic therapy enters the conversation has been a persistent gap in coordinating care between the 2 specialties.

In the next episode, "What POTOMAC Data Means for Combination Therapy and Patient Selection," Tyson and Drakaki dig into what the POTOMAC trial data actually shows about disease progression, efficacy, and how to select the right patients for combination therapy.