The diagnosis of bladder cancer relies on a combination of clinical evaluation, laboratory testing, imaging, endoscopy, and pathologic confirmation. “The goal is to confirm the presence of the tumor, determine its extent, and define the histologic features that will guide treatment,” Óscar Rodríguez Faba, MD, a urologist and editor-in-chief of Actas Urológicas Españolas, the official scientific journal of the Spanish Association of Urology, told El Médico Interactivo, part of Medscape’s Professional network.

Cystoscopy is the gold standard diagnostic test because it allows for direct visualization of the bladder mucosa and identification of papillary, flat, or suspicious lesions suggestive of in situ carcinoma.

In recent years, the management of bladder cancer has undergone significant evolution, driven by advances in diagnosis, surgery, and systemic treatments, with the goal of improving early detection, optimizing treatment selection, and increasing patient survival.

In the diagnostic field, the urologist explained, in addition to conventional cystoscopy, enhanced optical imaging techniques have been incorporated, such as blue-light cystoscopy and narrow-band imaging, which increase the detection of carcinoma in situ and reduce residual disease following transurethral resection.

The specialist also highlighted the development of urinary biomarkers and molecular tests based on DNA, RNA, and methylation, along with the gradual incorporation of molecular classification and circulating tumor DNA, which paves the way for more personalized medicine — for diagnosis, prognostic stratification, and disease monitoring.

Treatment

Regarding treatment, robot-assisted radical cystectomy has established itself as a safe and effective alternative to open surgery in experienced centers. Randomized clinical trials and comparative studies have shown equivalent oncologic outcomes, with less blood loss, a lower need for transfusions, faster functional recovery, and a shorter hospital stay, noted Rodríguez Faba.

Likewise, intracorporeal urinary diversion has made it possible to replicate the functional outcomes of open surgery while minimizing surgical trauma, and the implementation of enhanced recovery after surgery protocols has helped accelerate postoperative recovery and reduce complications.

Furthermore, the therapeutic landscape has also changed substantially. In non-muscle-invasive bladder cancer, recent studies, such as POTOMAC, have shown a significant improvement in recurrence-free survival by adding durvalumab to standard bacillus Calmette-Guérin (BCG) treatment in high-risk patients. Furthermore, trials such as SunRISe-1 with TAR-200, KEYNOTE-057 with pembrolizumab, and studies with nadofaragene firadenovec have expanded treatment options for patients with BCG-unresponsive non-muscle-invasive bladder cancer.

In muscle-invasive bladder cancer, the NIAGARA trial has shown that adding durvalumab to neoadjuvant chemotherapy followed by adjuvant therapy improves event-free survival and overall survival, thereby solidifying the concept of perioperative immunotherapy.

Furthermore, the EV-302/KEYNOTE-A39 study has established the combination of enfortumab vedotin and pembrolizumab as the new standard of first-line treatment for patients with locally advanced or metastatic disease. Taken together, these advances reflect the transition toward a multidisciplinary and precision-based approach, in which the integration of new diagnostic technologies, minimally invasive surgery, and targeted therapies and immunotherapies is substantially changing the management of bladder cancer.

Personalized Medicine

The urologist pointed out that bladder cancer is a heterogeneous disease from a clinical, histopathologic, and molecular standpoint. Patients with the same tumor stage and grade may have very different clinical courses, with varying risks for recurrence, progression, and response to treatment. This heterogeneity highlights the limitations of a one-size-fits-all therapeutic approach and justifies the need to move toward personalized medicine, based on the biological characteristics of the tumor and the patient themselves.

However, advances in the molecular characterization of urothelial carcinoma have made it possible to identify different molecular subtypes with distinct biologic, immunologic, and prognostic profiles, some of which are associated with greater sensitivity to chemotherapy, immunotherapy, or targeted therapies. At the same time, the development of biomarkers such as circulating tumor DNA, programmed death-ligand 1 expression, alterations in genes related to DNA repair or fibroblast growth factor receptor 3 mutations — along with the emergence of increasingly precise urinary biomarkers — is facilitating a more rational selection of patients and closer monitoring of the disease.

The growing availability of new therapeutic options — including immunotherapy, antibody-drug conjugates, targeted therapies, and new intravesical strategies — makes it even more essential to identify the optimal treatment for each patient.

Appropriate Selection

In his opinion, the goal is no longer solely to treat the tumor but to select the strategy that offers the highest probability of benefit with the least possible toxicity, avoiding both overtreatment of patients with low-risk disease and undertreatment of those with biologically aggressive tumors.

In this context, personalized medicine represents one of the main challenges and opportunities in the management of bladder cancer. The integration of clinical, pathologic, radiologic, and molecular information will enable the development of more accurate predictive models in the coming years, optimize therapeutic decision-making, and lead to truly individualized treatment capable of improving both oncologic outcomes and patients’ quality of life.

Rodríguez Faba declared no conflicts of interest. 

This story was translated from El Médico Interactivo, part of the Medscape Professional Network.