Ask AI
Back Back
Urology Bladder Cancer
Perspectives on Today’s Urology Management of Patients With Bladder Cancer: Answers to Your Questions

Released: February 20, 2026

Sam S. Chang
Sam S. Chang, MD, MBA
Activity Information

Activity

Progress
1
Course Completed
Continue
Key Takeaways
  • For urologists, high-quality TURBT and accurate risk stratification are foundational to effective non–muscle-invasive bladder cancer (NMIBC) management.
  • In BCG-unresponsive NMIBC, expanding treatment options necessitate individualized shared decision-making that considers dosing burden, expected durability of response, comorbidities (eg, autoimmune disease, transplant), and patient preferences.
  • ctDNA is a promising adjunct in muscle-invasive disease and soon may play a role in risk stratification for high-risk NMIBC, although routine use is not yet guideline driven.

In this commentary developed from audience questions submitted during workshops held at AUA chapter meetings across the United States between September 2025 and January 2026, Sam S. Chang, MD, MBA, provides answers to these questions and addresses practical challenges urologists are facing in the contemporary management of bladder cancer.

Across all meetings, one theme was consistent: The pace of change in bladder cancer care is accelerating. New approvals, evolving definitions such as BCG-unresponsive disease, and emerging technologies like circulating tumor DNA (ctDNA) are reshaping conversations in both community and academic settings.

Returning to fundamentals, why does TURBT quality still matter?
Even with all the new drugs and new approvals, the basics still matter. A high-quality transurethral resection of bladder tumor (TURBT) is foundational. If you do not adequately resect, everything that follows becomes more difficult.

Accurate staging is critical. For T1 disease in particular, I strongly believe in a repeat TURBT. It allows for more accurate staging, and it clearly may have a therapeutic benefit as well. You would be surprised how often you find residual disease or even upstaging. That information changes management.

Risk stratification also starts with that initial resection. If the pathology is incomplete or the sampling is inadequate, you are making downstream decisions without the full picture. Whether you are talking about intravesical therapy, systemic therapy, or even cystectomy, those decisions only make sense if you truly understand the biology and extent of the disease.

So although the field is moving quickly, this part has not changed. If we do not get the TURBT right, we are already behind.

How should urologists think about incorporating ctDNA into bladder cancer management?
The short answer is that we are still learning. In muscle-invasive bladder cancer, it is reasonable to consider ctDNA after cystectomy to help guide discussions about adjuvant therapy, particularly in the context of potential de-escalation. That said, it has not yet been adopted into routine guideline-based practice.

In NMIBC, the data are even more preliminary. Early signals suggest that ctDNA positivity after TURBT may identify biologically aggressive or understaged disease. Current evidence is limited and involves relatively small patient numbers. For now, ctDNA should be viewed as an emerging adjunct for risk stratification rather than a standard ordering practice for urologists.

In community practice, incorporation should occur in coordination with medical oncology, especially when results could influence decisions about adjuvant immunotherapy. Over the next several years, ctDNA may become more integrated into care, particularly for high-risk disease.

With so many new options for BCG-unresponsive NMIBC, how do we choose?
Recent FDA approvals, including intravesical gene therapies, device-based therapies, and systemic immunotherapy, have expanded options for patients with BCG-unresponsive carcinoma in situ with or without papillary disease. A space that once offered very few options now includes several approved therapies, including systemic pembrolizumab, intravesical nadofaragene firadenovec-vncg, nogapendekin alfa inbakicept-pmln plus BCG, and the intravesical gemcitabine-releasing system (TAR-200).

The challenge is sequencing. We do not yet know the optimal order of these agents, and head-to-head comparative data are unlikely. Decision-making, therefore, becomes highly individualized. Some patients prioritize convenience, such as less frequent dosing schedules. Others prioritize durability of response. Some have contraindications to immune-based therapy, such as transplant recipients or patients with significant autoimmune disease.

Shared decision-making is critical. With adjuvant or bladder-preserving strategies, we will inevitably overtreat a proportion of patients. Clear discussions about benefits, risks, immune-related adverse events, and long-term durability are essential before referral or initiation of therapy. We are likely moving toward a model of lines of intravesical therapy rather than a single binary decision.

How should we manage high-risk NMIBC during ongoing BCG shortages?
BCG supply continues to be frustrating. It is not just the shortage; it is the inconsistency. When we have it, we prioritize full-dose induction for the highest-risk patients, especially T1 and carcinoma in situ. Those are the patients who need it most.

If supply is tight, we will sometimes reduce the dose. If we do not have any at all, we move to gemcitabine usually with docetaxel. That has become our go-to alternative in that setting. In papillary-only disease, we may use gemcitabine alone. For patients with very high–risk features such as variant histology, extensive T1 disease, or prostatic urethral involvement, we have a different conversation. Those are the patients where we really need to think seriously about moving to timely cystectomy rather than continuing to cycle through intravesical therapies.

In BCG-unresponsive disease, how do we balance efficacy, toxicity, and durability?
There is not one number or one endpoint that makes the decision for you. It really depends on the patient. Some patients care most about convenience. Others are very concerned about systemic adverse effects, especially immune-related toxicities.

Systemic treatment with pembrolizumab can give you durable responses, but you are also buying the risk of immune-related adverse events. The intravesical gene therapies and viral therapies are generally well tolerated, but we still need longer follow-up to understand durability. Some of the device-based options look promising, but we are still early in the real-world experience.

In younger patients with aggressive T1 disease and other high-risk features, you have to be careful about stretching out bladder preservation too long. For some of those patients, cystectomy is still the safest oncologic choice. Dragging them through multiple salvage attempts without durable control can hurt them in the long run.

At the end of the day, this has to be individualized. There is no rigid formula that works for everyone.

Looking ahead
Bladder cancer care is moving fast right now. The guidelines are updating frequently, and it feels like every few months, there is a new approval or new data set to think about. Treatments are moving earlier in the disease course, and we still do not have clear answers on sequencing. That makes communication with our medical oncology and radiation oncology colleagues even more important. For urologists, however, the fundamentals have not changed:

  • We need to deliver a high-quality TURBT and make sure the staging is accurate
  • We need to apply risk stratification thoughtfully and consistently
  • We need to work closely with our multidisciplinary teams
  • We need to have honest, shared decision-making conversations with patients
  • And we need to stay flexible because the data are going to keep evolving

Your Thoughts
In your practice, what factors most influence decision-making for BCG-unresponsive NMIBC, and how are you thinking about emerging tools like ctDNA in risk assessment? Share your perspectives below!

Continue

Poll

1.

In your current practice, what is the primary factor guiding your treatment selection and sequencing for patients with BCG-unresponsive NMIBC?

Submit