Dr. Amanda Nizam

And that's what we're still finessing at this point.

By calling it stage two?

No, I think, you know, the way I approach my discussions with my patients, I don't like to use stage number when we're talking about bladder cancer because it can be a bit confusing.

I like to discuss it by non-muscle invasive, muscle invasive, and then either locally advanced, so like lymph node metastases only, or metastatic.

I feel like that's a better...

And then when we're talking about metastatic to lymph node only, I feel like that's a very, very gray area where there's going to be a lot of art to the medicine, especially precision medicine, because some of these patients may be curable with systemic therapy and then consolidative surgery after that.

But for stage two for muscle-invasive bladder cancer, again, we are treating a systemic disease.

We're trying to treat the micrometastatic disease and obviously downstage the tumor as well.

But when I talk to patients, basically, if they are going for radical cystectomy, then when we talk about prognosis, traditionally, we've discussed a pathologic stage.

But now we're bringing in ctDNA status and kinetics and a longitudinal ctDNA results into that discussion.

So, well, I think that comes down to the health system and financial reasons as well.

Reimbursement in the U.S., as you mentioned, is much more surgically heavy.

The uptake on bladder sparing therapy has been less than Europe.

But I think it honestly depends on which centers you're at, too.

Some centers are more bladder-friendly or bladder-sparing-friendly.

Whereas others are very high volume surgical centers, and those tend to be a little more biased in favor of radical mastectomy approaches.

But I think, as Brad said, with these improving systemic therapies, there's going to be a lot more people that can spare their bladders.

There are some ongoing trials right now.

Like, for example, Vadim Koshkin at UCSF has a trial of EV Pembro with chemoradiation for bladder sparing patients.

therapy in muscle-invasive bladder cancer.