NCCN guidelines adopt IBCG risk model for intermediate-risk NMIBC

The 2026 update to the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology for Bladder Cancer introduces a structured risk stratification framework for patients with intermediate-risk non–muscle-invasive bladder cancer (NMIBC), a population historically characterized by clinical heterogeneity and variable management strategies. The incorporation of the International Bladder Cancer Group (IBCG) 5-factor model aims to refine treatment decision-making by subdividing this group into clinically actionable categories.

Intermediate-risk NMIBC has long represented a “middle” category between low- and high-risk disease, leaving clinicians with unclear guidance on how to manage these patients. By integrating the IBCG model, the NCCN now stratifies patients into 3 clinically actionable subgroups: lower risk (0 factors), intermediate risk (1–2 factors), and higher risk (≥3 factors). The IBCG framework is based on 5 clinicopathologic risk factors associated with recurrence and progression: tumor multifocality, tumor size of 3 cm or larger, early recurrence within 1 year, frequent recurrences (>1 per year), and prior failure of intravesical therapy.

"For decades, intermediate-risk bladder cancer has been a highly heterogeneous, catch-all category that left patients vulnerable to both over- and undertreatment," said Ashish M. Kamat, MD, MBBS, president of the IBCG and professor of urologic oncology (surgery) at UT MD Anderson Cancer Center. "Through this framework, clinicians can safely de-intensify care for appropriate patients while ensuring that those with higher-risk features receive the adjuvant therapies they need. The NCCN's adoption of this model represents an important step toward more precise and standardized care for bladder cancer patients."

The 5-factor model was initially proposed in 2014 as a clinically pragmatic approach to defining intermediate-risk disease and guiding management. A subsequent update published in 2022 refined the scoring system, formally incorporating prior intravesical therapy failure as an independent risk factor and clarifying that high-grade tumors should be excluded from the intermediate-risk category. This distinction aligns with contemporary understanding that high-grade disease warrants management along high-risk pathways.

Validation efforts have supported the model’s prognostic utility. A 2024 multicenter retrospective analysis of 677 patients conducted by the Young Academic Urologists Urothelial Working Group demonstrated that the IBCG model accurately stratified patients into groups with significantly different risks of recurrence and progression.²

In addition, prospective data from the Bladder Cancer Italian Active Surveillance (BIAS) cohort showed that patients with no risk factors were more likely to continue active surveillance at 24 months compared with those with at least 3 risk factors (59% vs 24%). On multivariable analysis, the scoring system was also shown to be associated with subsequent transurethral resection of bladder tumor (1-2 risk factors: HR, 1.66; 95% CI, 0.96 to 2.90; P = .072; ≥3 risk factors: HR, 3.21; 95% CI, 1.70 to 6.09, P < .001).³

According to the IBCG, this framework will help guide appropriate treatment strategies, minimizing treatment for lower-risk patients and ensuring that patients with higher-risk features receive more intensive therapies.

Wei Shen Tan, MD, PhD, FRCS, IBCG member and assistant professor of urology at Yale School of Medicine, emphasized the clinical relevance of the model’s integration into practice: “Intermediate-risk NMIBC has long needed a framework like this—one that gives clinicians the confidence to de-intensify care for patients who don't need aggressive treatment, and to intensify it for those who do. Seeing it incorporated into the NCCN guidelines is deeply gratifying.”

Roger Li, MD, of Moffitt Cancer Center, also highlighted the implications of the model beyond routine clinical care, stating, “The IBCG risk stratification system for intermediate risk NMIBC will not only help urologists and patients successfully navigate the complex landscape of this disease in the clinic but will also enhance clinical trial design and the interpretation of their results.”

REFERENCES

1. NCCN 2026 Bladder Cancer Guidelines Adopt IBCG Risk Stratification Model for Intermediate-Risk NMIBC. News release. International Bladder Cancer Group (IBCG). March 24, 2026. Accessed March 25, 2026. https://www.einpresswire.com/article/901009937/nccn-2026-bladder-cancer-guidelines-adopt-ibcg-risk-stratification-model-for-intermediate-risk-nmibc

2. Soria F, Rosazza M, Livoti S, et al. Clinical Validation of the Intermediate-risk Non-muscle-invasive Bladder Cancer Scoring System and Substratification Model Proposed by the International Bladder Cancer Group: A Multicenter Young Academic Urologists Urothelial Working Group Collaboration. Eur Urol Oncol. 2024 Dec;7(6):1497-1503. doi:10.1016/j.euo.2024.06.004

3. Tan WS, Contieri R, Buffi NM, et al. International Bladder Cancer Group Intermediate-risk Nonmuscle-invasive Bladder Cancer Scoring System Predicts Outcomes of Patients on Active Surveillance. J Urol. 2023;210(5):763-770. doi:10.1097/JU.0000000000003639