Bladder Cancer Awareness Month: To spare or not to spare

Bladder cancer has changed pace over the past few years. From a field with relatively limited innovation and low visibility at major congresses, it is now delivering plenary data and shifting how practice is evolving. For Bladder Cancer Awareness Month, we reflect on a growing discussion in the community around how central surgery really needs to be in delivering a cure.

What we’re seeing

Perioperative EV-pembro is expected to be a new standard of care in MIBC, across cisplatin-eligible¹ and ineligible populations². But the depth of response seen after the neoadjuvant portion alone raises an interesting question: do all patients still need to go on to surgery?

If patients are achieving complete responses before cystectomy, it becomes harder to justify a one-size-fits-all approach. And this is not just theoretical. Surgeons report going into planned cystectomies and finding a high rate of pathological complete responses, which is naturally prompting questions about how long this approach remains appropriate³.

Trials are now starting to test this directly. EV-209 (NCT07475806) is exploring EV-pembro without planned surgery. But as with many shifts in oncology, whether practice will wait for definitive data or start to move ahead of it remains to be seen.

A shift in thinking

While the latest data and clinical experience are starting to suggest a broader role for bladder-sparing approaches, this sits in tension with long-standing clinical instincts. Radical cystectomy has traditionally been seen as the most reliable route to cure. It offers a clear endpoint, removes the tumor, and aligns closely with how urologists define their role in the treatment pathway.

Bladder-sparing strategies, by contrast, introduce unpleasant ongoing surveillance, often involving frequent cystoscopies, along with a degree of uncertainty and a loss of surgical finality. Because of this, they have often been viewed as a compromise rather than an equivalent option.

Therefore, while there is clear interest in reducing treatment burden, there is a very real question around how comfortable the field is moving away from the reassurance that surgery provides, and what that means for the long-established role of urologists centered around local treatment.

Bridging the gap

Tools such as ctDNA and urinary DNA are likely to become increasingly important. They have the potential to support patient selection, provide confidence in cases where cystectomy is avoided or delayed, and help address some of the challenges around surveillance. We are not there yet, but each congress is adding to our understanding of ctDNA dynamics and the complementary role of uDNA, moving the field a step closer.

The ambition is clear. Bladder sparing remains one of the most compelling directions in MIBC. The challenge now is working out what needs to be in place to make it a reality. It is not only about the outcomes seen with emerging approaches, but also confidence in response assessment and surveillance, and a broader comfort with how clinical roles and expectations may need to evolve.

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