Clinicians are concerned about the overuse of Stereotactic Body Radiation Therapy (SBRT) for oligoprogressive disease, a practice dubbed 'Pokemon' (gotta catch 'em all). This approach of sequentially radiating new lesions can delay the start of more effective systemic therapies and is not considered a standard of care.
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The negative ANSA-RAD trial, when contrasted with the positive STAMPEDE trial, demonstrates that patient selection is paramount in adjuvant therapy. The difference in outcomes was driven by risk definition, not the drug. This reinforces that "negative" trials are clinically vital for defining which patient populations do not benefit, preventing widespread overtreatment.
A blinded central radiology review is not the absolute gold standard for assessing patient progression. Expert clinicians argue their holistic assessment, incorporating the patient's clinical status and other biomarkers alongside scans, provides critical context that a disconnected reviewer lacks.
The Uromigos score (0-3) provides a rapid expert consensus on new treatments. It bridges the gap between slow, formal guidelines and long, unprioritized lists of approved therapies, offering a more immediate assessment of a drug's place in the standard of care.
With highly active agents yielding 30% complete response rates, the immediate goal should be to cure more patients by exploring potent combinations upfront. While sequencing minimizes toxicity, an ambitious combination strategy, such as ADC doublets, offers the best chance to eradicate disease and should be prioritized in clinical trials.
High relapse rates (~70%) in surgery-alone arms of recent trials suggest most patients with muscle-invasive bladder cancer (MIBC) already have micrometastatic disease. This reframes the disease, prioritizing early systemic therapy over immediate surgery to achieve control and potential cure.
The Rampart study's use of the Leibovic score for risk stratification is a key strength. Unlike traditional TNM staging, this score more heavily weights tumor grade, which clinicians find to be a more granular and clinically relevant predictor of recurrence risk than just tumor size.
Experts warn against over-interpreting a single negative ctDNA test after surgery, clarifying that these patients still face a significant 25-30% risk of recurrence. The biomarker's true prognostic power comes from serial testing that shows a patient remains persistently negative over time.
The interpretation of ctDNA is context-dependent. Unlike in the adjuvant setting, in the neoadjuvant setting, remaining ctDNA positive post-treatment signifies that the current therapy has failed. These high-risk patients need a different therapeutic approach, not an extension of the ineffective one.
Expert consensus shows a major paradigm shift: perioperative systemic therapy (like EV-Pembro, scoring 2.9) is the undisputed standard for muscle-invasive bladder cancer. Approaches starting with cystectomy alone now score below 1.8, formally branding them as inferior options.
Experts are divided on the optimal strategy for CT-DNA negative patients post-surgery. One side advocates for monitoring to spare patients from unnecessary treatment toxicity, while the other questions if this delay is non-inferior to immediate adjuvant therapy, a critical question not yet answered by trials.