Dr. Amanda Nizam

So what that trial told us was that patients who do have ctDNA-positive disease after cystectomy are the ones who truly benefit from adjuvant systemic therapy.

We also saw data that was presented by Tom Powles at EUA

EAU-2024, which was the negative ctDNA surveillance arm.

And that showed that most patients, over 90% of patients, even at two years, remained disease-free from recurrence.

So this was the first trial to really validate basically

using ctDNA-positive disease to validate the benefit of adjuvant therapy.

Now, where that plays into our current perioperative sandwich approach remains to be seen.

So that will be interesting as we see ctDNA data from more perioperative trials like Niagara and EV303.

Yeah, so I was, yes, I was using ctDNA certainly in the adjuvant setting.

But I think after I saw the data from Niagara, and certainly the Envigro and one, I've actually started checking ctDNA at diagnosis and then tracking it because it does give prognostic information.

So I've started every time I even before I start therapy, I check ctDNA status, and then I check it not well, I guess I'll check it every six weeks.

at least going into cystectomy and then depending on the result after that will kind of determine the cadence post-cystectomy.

But I do find it is a helpful augment to scans in terms of getting prognosis.

Exactly.

That's the approach that I think more contemporary trials are going to take, especially when we're talking about precision medicine in bladder cancer.

I think that's really where the craft is going to be in the adjuvant setting in terms of de-escalation, escalation, switch therapy for those patients who still have ctDNA-positive disease, pathologically non-PASCR disease.

What do we do to those patients?

Are you going to give them Evpembro if they didn't have a great response to begin with?

Yeah, so NGS and the perioperative setting, it can give you information on the disease or the biology driving the disease.

So, and kind of give you a little bit of an estimate in terms of prognosis and what's driving that.