The MIBC Referral Gap: Why Half of Patients Miss Perioperative Therapy

Welcome back to another Urology Times Special Report series. In this episode, titled "The MIBC Referral Gap: Why Half of Patients Miss Perioperative Therapy," Joshua J. Meeks, MD, PhD, estimates that historically only about half of patients with muscle-invasive bladder cancer (MIBC) have been referred for guideline-recommended perioperative therapy, despite clear survival data supporting systemic treatment.

Meeks, the Edward M. Schaeffer, MD, PhD Professor of Urology and associate professor of urology, biochemistry, and molecular genetics at Northwestern University Feinberg School of Medicine in Chicago, Illinois, walks through the traditional barriers driving that gap: a shortage of medical oncologists relative to demand, and a cohort of patients who were clearly platinum-ineligible—those with poor performance status, advanced age, creatinine above 1.5 or GFR below 45, or severe hearing loss—for whom a referral visit felt pointless. He also points to a psychological barrier: Many patients shut down once bladder removal enters the conversation and simply ask what alternatives exist, causing some to disengage from surgery altogether.

Meeks argues that improved systemic therapy is now reshaping that calculus and opening doors that were previously closed. He reviews what the data show happens to untreated MIBC: Most patients die of their cancer within a year without any treatment. Among those who proceed straight to cystectomy, results diverge—some do well, but many have more advanced disease that surgery alone cannot address, since it may reset the clock without curing the underlying cancer. That leaves a race to deliver adjuvant therapy, and Meeks notes that roughly half of patients who need it cannot receive it because of the surgery's impact on their health. Others end up in trimodal therapy pathways that still require urologist-to-specialist coordination, and a final group receives only repeat transurethral resections—an approach that may help with indolent, localized disease but leaves micrometastatic disease, the real driver of mortality, unaddressed. That gap, Meeks explains, is exactly why getting patients into systemic therapy discussions matters so much.

In the next episode, "FDA Expands MIBC Approval: What Changed for Platinum-Eligible Patients," Meeks turns to the FDA decision reshaping who qualifies for this regimen, breaking down what changed on July 10 and why the eligibility distinction between patient groups largely disappears.