{"entity":{"id":"muscle-invasive-bladder-cancer","kind":"cancer","name":"Muscle-invasive and advanced bladder cancer","aka":["MIBC","Invasive urothelial carcinoma","Metastatic urothelial carcinoma"],"tldr":"Once bladder cancer has grown into the muscle it needs more than scraping out: chemotherapy then removal of the bladder, or chemoradiation to keep it. For cancer that has spread, the antibody-drug conjugate enfortumab vedotin with pembrolizumab has replaced platinum chemotherapy as the first treatment.","summary":"Muscle-invasive urothelial carcinoma is treated with cisplatin-based neoadjuvant chemotherapy followed by radical cystectomy and urinary diversion, or by trimodality bladder preservation (maximal resection plus chemoradiation) in suitable patients. Perioperative immunotherapy has entered practice: adjuvant nivolumab after cystectomy (CheckMate 274) and durvalumab with neoadjuvant chemotherapy and after surgery (NIAGARA), which improved overall survival. For metastatic disease, enfortumab vedotin with pembrolizumab nearly doubled survival compared with platinum chemotherapy (EV-302) and became the standard first-line treatment in 2023; erdafitinib is used for FGFR3-altered tumours, and platinum chemotherapy followed by avelumab maintenance remains an option. Molecular subtypes (luminal, basal) and circulating tumour DNA are being used to select who needs adjuvant treatment.","asOf":"2026-09-17","wikipedia":"https://en.wikipedia.org/wiki/Bladder_cancer","links":[{"label":"Wikipedia","url":"https://en.wikipedia.org/wiki/Bladder_cancer"}],"tags":["subtype-page"],"related":[],"cancers":[],"sections":[],"technologies":[],"targets":[],"drugs":[],"companies":[],"institutions":[],"pathways":[],"terms":[],"trials":[],"people":[],"bottlenecks":[],"keyPapers":[],"journals":[],"notes":[],"group":"genitourinary","burden":"About a quarter of bladder cancers at diagnosis plus those that progress from superficial disease; half of patients with muscle invasion die of it within five years despite surgery, and metastatic disease had a median survival near a year until antibody-drug conjugates and immunotherapy changed it.","subtypes":["Muscle-invasive, organ-confined (T2)","Locally advanced (T3 to T4, node-positive)","Metastatic urothelial carcinoma","FGFR3-altered urothelial carcinoma","Variant histologies (squamous, small cell, plasmacytoid, micropapillary)"],"biomarkers":["Cisplatin eligibility (kidney function, hearing, performance status)","PD-L1 expression (selects immunotherapy in some settings)","FGFR3 mutations and fusions (erdafitinib)","Nectin-4 expression (near universal; enfortumab vedotin target)","Circulating tumour DNA after cystectomy (adjuvant selection)"],"standardOfCare":[{"setting":"Muscle-invasive, cisplatin-eligible","approach":"Neoadjuvant cisplatin-based chemotherapy (dose-dense MVAC or gemcitabine-cisplatin) with durvalumab (NIAGARA), then radical cystectomy with lymph node dissection and adjuvant durvalumab; adjuvant nivolumab for high-risk residual disease (CheckMate 274).","refs":["cisplatin","gemcitabine","durvalumab","niagara","cystectomy","nivolumab","checkmate-274"]},{"setting":"Bladder preservation","approach":"Maximal transurethral resection followed by chemoradiation, with salvage cystectomy for recurrence, in patients with unifocal tumours and no carcinoma in situ or in those unfit for surgery.","refs":["imrt-igrt","radiosensitisers","cisplatin"]},{"setting":"Metastatic, first line","approach":"Enfortumab vedotin plus pembrolizumab (EV-302); gemcitabine-platinum followed by avelumab maintenance where the combination is unavailable.","refs":["enfortumab-vedotin","pembrolizumab","ev-302"]},{"setting":"Later lines","approach":"Erdafitinib for FGFR3 alterations; platinum chemotherapy or enfortumab vedotin if not given first line; clinical trials.","refs":["erdafitinib","fgfr3-receptor","enfortumab-vedotin"]}],"stateOfArt":["EV-302 was the first trial in forty years to beat platinum chemotherapy first line, and it did so by a wide margin.","Perioperative immunotherapy now improves survival around cystectomy, and circulating tumour DNA promises to select who needs it.","Bladder preservation with chemoradiation gives survival similar to cystectomy in selected patients and is under-used."],"history":[{"year":1985,"title":"MVAC chemotherapy established for advanced disease","refs":["cisplatin"]},{"year":2003,"title":"Neoadjuvant MVAC improves survival before cystectomy (SWOG 8710)","refs":["cisplatin"]},{"year":2016,"title":"Atezolizumab: first immunotherapy approval in bladder cancer","refs":[]},{"year":2019,"title":"Erdafitinib: first targeted drug for FGFR3-altered urothelial cancer","refs":["erdafitinib"]},{"year":2021,"title":"Adjuvant nivolumab (CheckMate 274)","refs":["checkmate-274"]},{"year":2023,"title":"EV-302: enfortumab vedotin plus pembrolizumab replaces platinum first line","refs":["ev-302"]},{"year":2024,"title":"NIAGARA: perioperative durvalumab improves survival","refs":["niagara"]}],"pipeline":["durvalumab","erdafitinib","enfortumab-vedotin"],"openProblems":["Cisplatin-ineligible patients still have fewer options.","Choosing between cystectomy and bladder preservation lacks randomised evidence.","Variant histologies are excluded from most trials.","Cost and access to antibody-drug conjugates."],"parent":"urothelial"},"route":"/cancers/muscle-invasive-bladder-cancer/","neighbours":{"drug":[{"id":"cisplatin","kind":"drug","name":"Cisplatin","route":"/drugs/cisplatin/"},{"id":"durvalumab","kind":"drug","name":"Durvalumab","route":"/drugs/durvalumab/"},{"id":"enfortumab-vedotin","kind":"drug","name":"Enfortumab vedotin","route":"/drugs/enfortumab-vedotin/"},{"id":"erdafitinib","kind":"drug","name":"Erdafitinib","route":"/drugs/erdafitinib/"},{"id":"gemcitabine","kind":"drug","name":"Gemcitabine","route":"/drugs/gemcitabine/"},{"id":"nivolumab","kind":"drug","name":"Nivolumab","route":"/drugs/nivolumab/"},{"id":"pembrolizumab","kind":"drug","name":"Pembrolizumab","route":"/drugs/pembrolizumab/"}],"trial":[{"id":"checkmate-274","kind":"trial","name":"CheckMate 274","route":"/trials/checkmate-274/"},{"id":"ev-302","kind":"trial","name":"EV-302 / KEYNOTE-A39","route":"/trials/ev-302/"},{"id":"niagara","kind":"trial","name":"NIAGARA","route":"/trials/niagara/"}],"term":[{"id":"cystectomy","kind":"term","name":"Radical cystectomy","route":"/terms/cystectomy/"}],"technology":[{"id":"imrt-igrt","kind":"technology","name":"IMRT / IGRT (modern external beam)","route":"/technologies/imrt-igrt/"},{"id":"radiosensitisers","kind":"technology","name":"Radiosensitisers","route":"/technologies/radiosensitisers/"}],"target":[{"id":"fgfr3-receptor","kind":"target","name":"FGFR3","route":"/targets/fgfr3-receptor/"}],"cancer":[{"id":"urothelial","kind":"cancer","name":"Bladder & urothelial cancer","route":"/cancers/urothelial/"}]}}