Referral Pathways and Unmet Needs in Perioperative MIBC Care

In this video, Joshua J. Meeks, MD, PhD, addresses how enfortumab vedotin-ejfv (Padcev) plus pembrolizumab (Keytruda) fits alongside other MIBC regimens, noting that the only real comparator, the gemcitabine-cisplatin-durvalumab (Imfinzi) regimen from the NIAGARA trial, has never been tested head-to-head against it. Meeks said he expects EV plus pembrolizumab to become the default choice for most patients now that it's FDA-approved, though he identifies one niche population—immunosuppressed patients, including transplant recipients, who cannot receive checkpoint inhibitor therapy—who will still need gemcitabine-cisplatin or enfortumab vedotin monotherapy, an approach he says hasn't been well studied.

Meeks outlines several open questions the field still needs to answer. Roughly a third to 40% of patients in the cystectomy population did not achieve a complete pathologic response, raising questions about whether that reflects intrinsic treatment resistance or simply a need for more cycles; he describes one patient who initially had residual cancer after 4 cycles but ultimately responded after additional therapy. He also points to biomarker-driven decision-making, such as using ctDNA status after 4 cycles to help decide between surgery and continued systemic therapy, along with broader questions about which patients can safely preserve their bladder and whether the full trial regimen can be de-intensified for lower-risk patients.

On practical referral steps, Meeks encourages community urologists without an in-house medical oncology partner to help patients find one locally, then take an active role in coordinating the treatment plan and cycle count. He frames 2026-era MIBC care as fundamentally a team effort requiring a multidisciplinary approach, and closes with a direct message to urologists: The data are compelling, but they only help patients who actually make it to medical oncology, so every referral conversation counts.