EvidenceMuscle-invasive and advanced bladder cancer

Patients fit enough for cisplatin whose bladder cancer has invaded the muscle wall should now be offered durvalumab with their pre-operative chemotherapy and for about a year after surgery, which improves the chance of cure without compromising the operation. The trial cannot say whether the adjuvant phase is necessary, or how to treat cisplatin-ineligible patients, for whom other trials are ongoing.

Almost every patient newly diagnosed with advanced bladder or urothelial cancer should now be offered enfortumab vedotin plus pembrolizumab rather than chemotherapy, with median survival extended from about 16 months to over two and a half years. Neuropathy and skin toxicity need monitoring and dose adjustment, and patients with severe diabetes or pre-existing neuropathy need care. Platinum chemotherapy remains an option for those who cannot receive the combination.

For patients who still receive platinum chemotherapy first, avelumab maintenance rather than observation is the standard next step. Where enfortumab vedotin plus pembrolizumab is available first line, this sequence is used less.

Fit patients with muscle-invasive bladder cancer should be offered cisplatin-based chemotherapy before cystectomy; a complete pathological response predicts cure. Newer regimens such as gemcitabine-cisplatin and dose-dense MVAC, and now durvalumab, build on this result.