Dr Arafat on Evolving Neoadjuvant Treatment Strategies in MIBC

“The emphasis on multidisciplinary decision-making and prioritizing the use of neoadjuvant chemotherapy [continue] to be a high priority."

Waddah Arafat, MD, an associate professor of internal medicine and a member of the Division of Hematology and Oncology at The University of Texas (UT) Southwestern Medical Center; as well as medical director of the Clinical Cancer Informatics Program at UT Southwestern Harold C. Simmons Comprehensive Cancer Center, discussed ​how the role of neoadjuvant chemotherapy for the treatment of patients with muscle-invasive bladder cancer (MIBC) has evolved with the addition of immunotherapy to this treatment paradigm.

Deficiencies in the use of neoadjuvant data within the United States health care system have been well documented, Arafat began. Although these circumstances have improved over the past 2 decades, notable shortcomings remain, he stated. These challenges are particularly evident in community-based oncology practices, where limited access to multidisciplinary care restricts collaboration between urologists and medical oncologists, he emphasized. Regardless of whether patients are treated in academic institutions or community settings, multidisciplinary decision-making and the prioritization of neoadjuvant chemotherapy remain critical components of optimal management, he said.

The integration of durvalumab with gemcitabine and cisplatin—as demonstrated in the NIAGARA trial of perioperative durvalumab (Imfinzi) plus neoadjuvant chemotherapy in cisplatin-eligible patients with MIBC—does not fundamentally alter these longstanding challenges, Arafat contextualized. Rather, these data reinforce the importance of administering neoadjuvant therapy to achieve higher pathologic complete response (pCR) rates, as pCR has been consistently validated as a strong predictor of favorable long-term outcomes, he noted. Current evidence clearly supports the role of perioperative chemotherapy in improving survival outcomes, with the most substantial and evidence-based benefits observed in the neoadjuvant setting, according to Arafat.

Uncertainty persists regarding the precise mechanisms underlying this advantage, Arafat continued. The bladder cancer treatment field is uncertain of whether improved outcomes with the NIAGARA regimen result primarily from enhanced surgical resection following tumor downstaging or from the early eradication of micrometastatic disease prior to definitive surgery, he reported. Nevertheless, the cumulative data underscore the necessity of prioritizing neoadjuvant therapy within multidisciplinary treatment paradigms to optimize patient outcomes, he concluded.