Bladder & urothelial cancer: lines of therapy

Cancer page →

12 standard-of-care settings across 5 lines and 2 biomarker subgroups. Rows come from the cancer page's standard of care; the grid places each on its line and subgroup.

Line	All comers	Risk group
Screening, prevention and diagnosis	1	·
Early / localised	3	2
Advanced, first line	2	·
Third line and beyond	1	·
Other settings	3	·

Screening, prevention and diagnosis

Subgroup	Setting	Approach	Products and trials	Guideline	Evidence
All comers	Diagnosis and surveillance	Cystoscopy (white or blue light) and TURBT with muscle in the specimen; re-resection for T1; CT urography; urine cytology; surveillance cystoscopy every 3-12 months by risk.	Cystoscopy, blue-light imaging & TURBTCT (computed tomography)	NCCN · Bladder cancer guideline	40

Early / localised

Subgroup	Setting	Approach	Products and trials	Guideline	Evidence
All comers	NMIBC	TURBT + intravesical BCG; novel intravesical agents for BCG-unresponsive; durvalumab + BCG for high-risk (2026).	DurvalumabOncolytic virusesCytokines & engineered cytokines	NCCN Guidelines: Bladder Cancer	86
All comers	BCG-unresponsive NMIBC (CIS ± papillary)	Radical cystectomy remains the oncologic gold standard; bladder-sparing options: TAR-200 (Inlexzo, 2025), N-803 + BCG (Anktiva, 2024), nadofaragene firadenovec (2022), pembrolizumab (2020); cretostimogene in registration.	Gemcitabine intravesical system (TAR-200)Nogapendekin alfa inbakiceptNadofaragene firadenovecPembrolizumabCretostimogene grenadenorepvecSunRISe-1BOND-003QUILT 3.032	NCCN · 2A (intravesical options); cystectomy prefe…	98
All comers	After cystectomy (no perioperative IO)	Adjuvant nivolumab for high-risk pathology (CheckMate 274); or ctDNA-guided adjuvant atezolizumab (IMvigor011, approved 2026).	NivolumabCheckMate 274AtezolizumabIMvigor011Signatera	NCCN · 1 (nivolumab); ctDNA-guided atezolizumab new	88
Risk group	Low / intermediate-risk NMIBC	TURBT with single immediate intravesical chemotherapy instillation; intermediate risk adds 1 year of intravesical chemotherapy (gemcitabine/mitomycin) or BCG.	Cystoscopy, blue-light imaging & TURBTIntravesical therapy (BCG, chemotherapy, devices, gene and viral therapy)	NCCN · 1 (single postoperative instillation)	87
Risk group	High-risk NMIBC, BCG-naive	TURBT then BCG induction and 1-3 years maintenance; durvalumab + BCG approved May 2026 (POTOMAC); radical cystectomy for very high-risk (T1 + CIS, variant histology).	Intravesical BCGDurvalumabPOTOMACDurvalumab + BCG in BCG-naive high-risk NMIBC	NCCN · 1 (BCG maintenance); durvalumab + BCG newly…	89

Advanced, first line

Subgroup	Setting	Approach	Products and trials	Guideline	Evidence
All comers	Metastatic	Enfortumab vedotin + pembrolizumab; erdafitinib (FGFR3); platinum + nivolumab.	EV-302 / KEYNOTE-A39Enfortumab vedotinPembrolizumab	ESMO-MCBS · 4 (EV-301 enfortumab vedotin); 3 (TROPHY-U-…	98
All comers	Metastatic, first line	Enfortumab vedotin + pembrolizumab (EV-302); if contraindicated, platinum-gemcitabine followed by avelumab maintenance (JAVELIN Bladder 100) or nivolumab + gemcitabine-cisplatin (CheckMate 901).	Enfortumab vedotinPembrolizumabEV-302 / KEYNOTE-A39AvelumabJAVELIN Bladder 100Nivolumab	NCCN · 1 (preferred: EV + pembrolizumab)ESMO-MCBS · 4	98

Third line and beyond

Subgroup	Setting	Approach	Products and trials	Guideline	Evidence
All comers	Metastatic, later lines	Erdafitinib if FGFR3-altered (THOR); platinum chemotherapy if not yet given; disitamab vedotin ± toripalimab (HER2, China); sacituzumab govitecan (US indication withdrawn 2024); trials of TROP2/HER2/bispecific ADCs and sac-TMT.	ErdafitinibTHORDisitamab vedotinSacituzumab tirumotecanIzalontamab brengitecanAK146D1	NCCN · 1 (erdafitinib, FGFR3+)	92

Other settings

Subgroup	Setting	Approach	Products and trials	Guideline	Evidence
All comers	MIBC	Neoadjuvant chemo ± durvalumab → cystectomy → ctDNA-guided atezolizumab or nivolumab.	IMvigor011AtezolizumabSignatera	NCCN Guidelines: Bladder Cancer	88
All comers	Muscle-invasive, cisplatin-eligible	Perioperative EV + pembrolizumab (EV-304, positive 2025; filing) or neoadjuvant durvalumab + gemcitabine-cisplatin with adjuvant durvalumab (NIAGARA, approved 2025), then radical cystectomy with lymph node dissection; trimodality bladder preservation (TURBT + chemoradiation) for selected patients.	Enfortumab vedotinPembrolizumabEV-304 / KEYNOTE-B15DurvalumabNIAGARAIMRT / IGRT (modern external beam)Enfortumab vedotin + pembrolizumab across the bladder cancer continuum	NCCN · 1 (NIAGARA regimen); EV+pembro pending labelESMO-MCBS · A (NIAGARA)	98
All comers	Muscle-invasive, cisplatin-ineligible	Perioperative EV + pembrolizumab with cystectomy (EV-303, approved Nov 2025); or cystectomy alone / chemoradiation.	Enfortumab vedotinPembrolizumabEV-303 / KEYNOTE-905	NCCN · 1ESMO-MCBS · A	98

Regimens in the library

Gemcitabine + cisplatin Sacituzumab govitecan Dose-dense MVAC Enfortumab vedotin + pembrolizumab Intravesical BCG, induction and maintenance

Lines and subgroups are parsed from the setting text of each standard-of-care row and can misclassify an unusual phrasing; the row’s own setting is always shown. Guideline chips reflect the NCCN category and ESMO-MCBS grade recorded on the cancer page, checked on its stated date. Not medical advice.