For patients with locally advanced bladder cancer achieving a complete response to potent systemic therapies, experts increasingly argue against consolidative surgery. They believe such effective treatments, a stark contrast to older options, may make the risks of a major operation an unnecessary "overkill" for achieving long-term control.
Despite excellent responses to systemic therapy in very locally advanced bladder cancer, some experts still advocate for surgery. They argue that even with a complete radiological response, a surgical intervention might represent the only "window of opportunity for cure" by eradicating residual microscopic disease and should remain a key discussion point.
While positive ctDNA is a clear indicator of disease, a negative result must be interpreted with caution. Clinical trial data shows even ctDNA-negative patients can benefit from adjuvant therapy, suggesting undetectable levels do not guarantee the absence of micrometastatic disease that still requires treatment to prevent recurrence.
A dual-biomarker approach may revolutionize bladder cancer monitoring. Experts suggest urinary tumor DNA (utDNA) is superior for assessing the local tumor in the bladder wall, while circulating tumor DNA (ctDNA) monitors systemic disease. A negative result on both tests could provide the confidence needed to safely skip radical cystectomy.