J Korean Med Assoc.  2025 Apr;68(4):215-227. 10.5124/jkma.25.0063.

Personalizing perioperative therapy in muscle-invasive bladder cancer: balancing oncologic benefit, toxicity, and the risk of overtreatment

• Song G
• Kwon WA
• Jung EH
• Phuc Vo DH
• Tan Truong HT
• Seo HK

• KMID: 2568118
• DOI: http://doi.org/10.5124/jkma.25.0063

Abstract

Purpose
Muscle-invasive bladder cancer (MIBC) is an aggressive cancer with a high recurrence risk due to micrometastases. Standard treatment, neoadjuvant cisplatin-based chemotherapy followed by radical cystectomy, is not suitable for all patients, with many being ineligible or experiencing recurrence, alongside significant toxicity concerns.
Current Concepts
The introduction of immune checkpoint inhibitors (ICIs) into the perioperative setting —including neoadjuvant ICI use in cisplatin-ineligible patients, adjuvant ICI use in high-risk individuals, and chemoimmunotherapy in either the preoperative or postoperative period—has demonstrated promising clinical outcomes. Additionally, bladder preservation strategies are currently under investigation in select patients who exhibit favorable treatment responses, aiming to maintain quality of life without compromising oncologic outcomes. Nevertheless, challenges such as overtreatment, long-term toxicity, and immune-related adverse events remain significant, underscoring the necessity for precise patient selection.
Discussion and Conclusion
To personalize perioperative management of MIBC, it is essential to develop and clinically implement robust predictive biomarkers. Assessment of molecular residual disease using circulating tumor DNA is emerging as a promising method to stratify risk, guide adjuvant treatment decisions, and monitor therapeutic response in real time. Future research should prioritize the validation of these biomarkers, refinement of patient selection criteria for bladder preservation strategies, and evaluation of novel therapeutic agents such as antibody-drug conjugates and fibroblast growth factor receptor inhibitors in the perioperative setting. Ultimately, adopting a precision oncology approach will be critical for balancing oncologic efficacy with toxicity management and achieving patient-centered outcomes.

Keyword

Cystectomy; Cystectomy; Cystectomy; Immune checkpoint inhibitors; Immune checkpoint inhibitors; Immune checkpoint inhibitors; Precision medicine; Precision medicine; Precision medicine; Quality of life; Quality of life; Quality of life; Urinary bladder neoplasms; Urinary bladder neoplasms; Urinary bladder neoplasms; 방광절제; 방광절제; 면역체크포인트억제제; 면역체크포인트억제제; 정밀의학; 정밀의학; 삶의질; 삶의질; 방광 신생물; 방광 신생물