Keeping Patients With MIBC on Track From TURBT to Neoadjuvant Therapy

Li explains that a diagnosis of muscle-invasive bladder cancer (MIBC) is frightening, and some patients block out the diagnosis and do not follow up, missing the window to cure their disease. It is incumbent on urologists, he argues, to guide these patients: to let them know that very effective treatments are available, and to help them see surgery as life-altering but not something to fear, with the expectation of life after cystectomy.

Because most patients with MIBC are still diagnosed in the community, Li says shortening the interval to treatment ultimately comes down to a good relationship between the urologist and the medical oncologist. Moffitt urologists work with in-house medical oncologists and with community oncologists comfortable giving the enfortumab vedotin-ejfv (Padcev)–pembrolizumab (Keytruda) sandwich regimen. Keeping communication channels open, he says, facilitates quick consultations and timely initiation of systemic therapy.

Li adds that patients who were ineligible for cisplatin were historically the ones considered for upfront radical cystectomy. With enfortumab vedotin plus pembrolizumab now available and its pCR, EFS, and OS results, he says, practice patterns for these patients should change.

On surgical timing, Li describes an evolving learning curve. Immune-related complications can delay surgery, he notes, and surgeons must decide whether a patient should continue at a reduced dose or stop the course early to proceed to cystectomy. There is no set approach yet, but he expects baseline tumor characteristics, longitudinal ctDNA, and real-world experience to help guide that decision.

In the next segment, Li discusses the urologist's role in recognizing toxicities, the open questions around adjuvant therapy, and the single practice change he believes matters most.