Laura Bukavina, MD, discusses debate on high-grade tumor risk stratification

In an interview at the 2025 Society of Urology Oncology Annual Meeting in Phoenix, Arizona, Laura Bukavina, MD, MPH, MSc, recapped a debate that she moderated titled, “Should high grade tumors be included in IR-NMIBC?”

Bukavina is an assistant professor of Urologic Oncology at Cleveland Clinic Glickman Urologic Institute, and translational science lead in GU oncology at Cleveland Clinic Lerner College of Medicine in Cleveland, Ohio.

“There's a lot of discrepancy in what we define as intermediate risk vs high risk. As we know, if we define it as a [different] risk category, it significantly changes how we treat these patients,” Bukavina explained. “The debate was really focused [on whether] we [should] upstage, in terms of risk, the Ta high grade tumors to a higher risk category where they're treated more aggressively, or should we continue to stratify them in the intermediate risk [category].”

Participants highlighted that intermediate-risk bladder cancer is a highly heterogeneous group, often serving as a “catch-all” category. Retrospective data suggest that Ta high-grade tumors behave more like high-risk disease, with higher rates of recurrence and progression than typical intermediate-risk or low-grade tumors.

Opponents of upstaging argued that while Ta high-grade tumors are indeed higher risk, they still do not reach the severity of T1 high-grade disease. Reclassifying them could lead to overtreatment and unnecessary toxicity.

Bukavina also emphasized moving beyond traditional clinical and pathological criteria in making these decisions.

“We looked a lot at the past in terms of retrospective studies and past things that have been published. One of the arguments that I made is that we should be looking to the future,” Bukavina concluded. “We should be looking at things more objectively by using next-generation sequencing. We're [also] looking at potentially AI pathology that helps standardize and looks at the biology of disease, looking at the tumor itself to provide those risk categories, and less so at just those clinical characteristics.”