| Setting | Treatment |
|---|---|
| NMIBC — Ta / T1 / CIS no muscle invasion (~75%) | The TURBT has already treated it Then intravesical BCG for high-risk, or intravesical chemo BCG-unresponsive → pembrolizumab · nadofaragene · cystectomy |
| MIBC — cisplatin-FIT ≥T2, no mets, CrCl ≥60 | Neoadjuvant chemo-IO → RADICAL CYSTECTOMY + PLND → adjuvant IO Standard: durvalumab + gem/cis ×4 → cystectomy → durvalumab ×8 cycles (NIAGARA) ⚠ The adjuvant course is FINITE — 8 cycles, then STOP
not "until progression" Alternative adjuvant if high-risk post-op → nivolumab ×1 yr (CheckMate-274) |
| MIBC — cisplatin-UNFIT CrCl <60 · ECOG ≥2 · neuropathy · hearing loss · HF | Perioperative EV + pembrolizumab — 3 neoadjuvant cycles → CYSTECTOMY + PLND → adjuvant pembrolizumab (EV-303 / KEYNOTE-905)
pCR 57% vs 9%; OS not reached vs 41.7 mo · carboplatin is NOT an adequate substitute — this replaced it ⚠ No bladder-preservation arm — the benefit was earned WITH cystectomy Truly unfit for surgery → trimodality / RT |
| MIBC — BLADDER PRESERVATION refuses/unfit for cystectomy, or favourable: solitary, <5 cm, fully resected at TURBT, no hydronephrosis, no extensive CIS | TRIMODALITY THERAPY = ① maximal TURBT → ② radiotherapy → ③ concurrent radiosensitiser
cisplatin · 5-FU + mitomycin (BC2001) · gemcitabine if cisplatin-unfit ⚠ Non-negotiable: LIFELONG cystoscopy — the bladder is still there
salvage cystectomy is the bail-out ⚠ Adjuvant IO after TMT is NOT established
all the evidence ((NIAGARA) (CheckMate-274)) is post-CYSTECTOMY; the trials built for this question ((S1806) (KEYNOTE-992)) have not reported. If given anyway, every framework is finite, ~6–8 months ctDNA to SELECT rather than treat blindly (IMvigor011)
see ctDNA in Tools · ⚠ ctDNA does NOT survey the bladder — cystoscopy stays independent |
| METASTATIC | 1st line → EV + pembrolizumab (EV-302)
enfortumab vedotin, a Nectin-4 ADC — replaced platinum chemo Alternative → platinum + gemcitabine → avelumab maintenance (JAVELIN Bladder 100) FGFR-altered → erdafitinib |