Félix Guerrero-Ramos, MD, PhD, FEBU, discusses when to intensify and when to hold back in MIBC

Among the bladder cancer-related debates that took place at the 41st Annual European Association of Urology Congress in London, United Kingdom, was the discussion, “MIBC systemic therapy: Maximise early or strategise post-op?” In this video, Félix Guerrero-Ramos, MD, PhD, FEBU, a panelist during a discussion following the debate, makes the case for perioperative immunotherapy in muscle-invasive bladder cancer, grounding his argument in the most recent and compelling survival data while acknowledging that precision-based patient selection remains a work in progress. Guerrero-Ramos is the coordinator of the uro-oncology unit at the Hospital Universitario 12 de Octubre, Madrid, Spain.

On the rationale for early immunotherapy, Guerrero-Ramos points to the NIAGARA trial and the KEYNOTE-905/KEYNOTE B-15 trials as landmark evidence—the first time immunotherapy has demonstrated an overall survival benefit in this setting, across both BCG-unresponsive non-muscle-invasive and muscle-invasive disease. He acknowledges that some patients may not benefit from the adjuvant component, but notes that trials were designed on an intention-to-treat basis, meaning all patients were expected to receive both perioperative and adjuvant therapy—and that is the framework under which the survival benefit was demonstrated.

On patient selection, Guerrero-Ramos is candid that no validated predictive tools currently exist for the perioperative setting. However, exploratory data are emerging. Post-cystectomy circulating tumor DNA (ctDNA) status shows promise: ctDNA-positive patients face high recurrence risk and likely need intensified therapy, whereas ctDNA-negative patients generally have better outcomes. Nevertheless, the NIAGARA subanalysis suggests that even ctDNA-negative patients derive benefit from adjuvant durvalumab, complicating the picture. The one confirmed signal comes from the IMvigor011 trial, where ctDNA-negative patients did not appear to benefit from adjuvant atezolizumab (Tecentriq)—but this applies to adjuvant-only therapy, not the full perioperative approach.

On the urologist's role, Guerrero-Ramos is direct: Urologists must stay current with evolving evidence and engage proactively with medical oncology, ideally through multidisciplinary tumor boards, to ensure patients receive the best available systemic therapy before and after surgery.