RECENT advancements in bladder cancer treatment are transforming care, offering new hope to patients, particularly those with high-risk muscle-invasive disease. The integration of novel therapies and predictive biomarkers is paving the way for more personalised and effective treatment strategies.
For decades, platinum-based chemotherapy has been the cornerstone of care for both metastatic and muscle-invasive bladder cancer. In muscle-invasive cases, it is commonly used as neoadjuvant therapy before surgery. However, the treatment landscape has evolved with the introduction of immune checkpoint inhibitors. These drugs enhance the immune system’s ability to target cancer by inhibiting mechanisms that suppress immune activity. When combined with chemotherapy and innovative agents like enfortumab vedotin, an FDA-approved antibody-drug conjugate targeting nectin-4, these therapies significantly outperform chemotherapy alone.
The recent NIAGARA trial exemplifies this progress, investigating the combination of the immune checkpoint inhibitor durvalumab with chemotherapy before and after bladder-removal surgery. Results showed marked improvements in two-year survival rates, lower recurrence risks, and greater progression-free survival compared to chemotherapy alone. As the first randomised phase 3 trial to challenge the neoadjuvant standard for muscle-invasive bladder cancer, NIAGARA represents a critical step forward. However, its design did not isolate the specific contributions of pre- and post-surgical durvalumab, leaving important questions for future studies.
Predictive biomarkers are expected to play a pivotal role in further enhancing treatment outcomes. Biomarkers like circulating tumour DNA can identify patients at higher risk of recurrence and help determine who might benefit most from perioperative therapies. This tailored approach could refine treatment plans, minimising unnecessary interventions while maximising efficacy.
Combinations of immune checkpoint inhibitors and antibody-drug conjugates have also extended survival for patients with metastatic disease. Trials such as CheckMate 901 have demonstrated the success of combining agents like nivolumab, a PD-1 inhibitor, with traditional chemotherapy. These findings underline the value of blending established and innovative therapies.
Ongoing research continues to optimise these regimens, focusing on balancing efficacy with quality of life, reducing toxicity, and leveraging biomarkers to deliver precision care. These advancements bring a brighter future for patients battling bladder cancer.
Reference
Milowsky MI. Toward curing more patients with bladder cancer – a new perioperative strategy. N Engl J Med. 2024;391(19):1848-9.
