Dr. Brad McGregor

And so it was tough, right?

So a lot of the cases, patients were sort of being seen by surgeons and say, hey, this patient's dying, Elvis is flat and there's no need to see them or manage them.

And then we had the advent of immunotherapy and the advent of setting for the right patients.

And then more recently, now we have perioperative immunotherapy with cisplatin using split dose, getting GFR down to 40.

And then just in the past couple months, despite the government shutdown, we had rapid approval of EV with pembrolizumab in the perioperative setting, patients with cisplatin ineligible, and really sick patients, right?

Patients in their 70s, T3 disease, T4 disease.

No positive, showing not only improvement in GFS, but a marked improvement in overall survival versus cystectomy alone.

So I think the role of the medical oncologist is evolving rapidly.

And while we often would see these patients in the...

a select number in the pre-op setting, then all patient in the admin setting, I think it's becoming increasingly clear that we need to be seeing patients with muscle invasive bladder cancer as a multidisciplinary evaluation prior to their OR date.

Because

I think it's very clear that not only can we offer important therapeutic inventions by seeing patients earlier, but we also get important prognostic information through CT DNA and appropriate testing to help guide therapy in the future.

So I think it's a really exciting time to be treating patients with bladder cancer because I think we now have an opportunity to intervene on nearly every patient with muscle-based bladder cancer to improve their chance of a cure and long-term disease-free survival.

To Amanda's point, I think it's really important.

Like, we are talking now about a potential to cure patients, right?

And, you know, if we can offer intervention early on and cure patients with a defined course of therapy, despite the amazing results we have for, commonly seen, ED, PEM, or the metastatic setting, it's still going to be better to offer that.

And so, it really is critical now, perioperative intervention.

Immunotherapy and chemotherapy, be it cisplatin per the NAGA regimen or EV in the more recent EV303 data is really a standard of care.

And all patients should have the opportunity to discuss that opportunity.

So if you have a situation where you know you have muscle invasive bladder cancer and you're looking to go to cystectomy,