BackTable Urology
Ep. 287 Urothelial Carcinoma: Understanding CTDNA and Precision Medicine with Dr. Amanda Nizam and Dr. Brad McGregor
30 Jan 2026
Chapter 1: What is the main topic discussed in this episode?
This week on the Backtable Podcast.
Chapter 2: What are the latest advancements in bladder cancer treatment?
We are talking now about a potential to cure patients, right? And, you know, if we can offer intervention early on and cure patients, a defined course of therapy, despite the amazing results we have for comedy, say, ED, PEM, or the metastatic setting, it's still going to be better to offer that. And so, it really is critical now, perioperative therapy.
Chapter 3: How do patient staging and treatment goals evolve in muscle-invasive bladder cancer?
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.
My name is Alan Tan. I'm a medical oncologist at the Vanderbilt Ingram Cancer Center. It's my pleasure to host this discussion on bladder cancer or urothelial cancer with my good friends and GU experts in bladder cancer, Brad McGregor and Amanda Nizam. Brad, you want to introduce yourself?
Chapter 4: What are the differences between bladder preservation and radical cystectomy?
Yeah, excited to be here. I'm Brad McGregor. I'm at Dana-Farber in Boston, where we have less snow than Cleveland right now. Amanda?
I am Amanda Nizam. I'm a GU medical oncologist at Cleveland Clinic, where we have much more snow and frigid temperatures than Boston, surprisingly.
Chapter 5: What emerging trials are shaping the future of bladder cancer management?
Yeah, so I actually used to be in Chicago, so I'm no stranger to blizzards and snow starts. But now I'm here in Nashville where I'm actually craving some snow. We're going to go Friday to Park City for a nice ski trip for my wife's birthday. So that'll be nice. Anyways, such exciting time. I know we can talk for over an hour on urethelial cancer.
Chapter 6: How is ctDNA utilized in precision medicine for bladder cancer?
A lot has changed in the last few years. But we're medical oncologists, and we usually see disease in a setting called MIBC, or muscle-invasive bladder cancer, or muscle-invasive urethral cancer. Brad, why don't you start us off? How has this discussion changed in the past few years when you're talking to a patient? You refer to a patient by urology.
Patient has, say, T3 and zero disease, muscle invasive bladder cancer. They got tube RPT assessment. And what's the goal of the medical oncologist at this point?
I mean, I think it's changing at a rapid pace. And I think it used to be we had data. I mean, go back at some initial data, SWOG trials from the 90s, early 2000s, where it showed that neoadjuvant
Chapter 7: What role do biomarkers like HER2 and FGFR play in treatment selection?
dose-dense MVAC improved overall survival. We had meta-analysis, about a 5% improvement in five-year-old survival with aggressive cisplatin neoadjuvant-based chemotherapy. Added cisplatin-based therapy didn't work, right?
So in this situation where if a patient was LF cisplatin, they really should be getting neoadjuvant cisplatin-based therapy because it's hard to give cisplatin-based chemotherapy. chemotherapy, but that's about half of the patients. I mean, patients with bladder cancer are sick. They're older, comorbidities, poor renal function. 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.
Chapter 8: How can treatment-related toxicities, like neuropathy, be managed?
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.
Yeah, I totally agree, Brad. Amanda, like when you talk to a patient, they ask what stage the cancer is. What stage do you tell them?
In the muscle invasive setting?
Yeah, say T2 and 0.
Yeah, so T2N0, you know, we explain it. I show them a diagram of the bladder and the layers of the, you know, superficial layers and the detrusor muscle layer, the perivascular fat. So I explain it that way. And then I also kind of, when I talk to them about perioperative therapy, I talk to them and kind of use the analogy of a weed killer because we're not just treating only to shrink the tumor.
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