For locally advanced bladder patients who achieve a complete clinical response to neoadjuvant EV + pembrolizumab but subsequently decline cystectomy, how do you approach the decision between active surveillance and consolidative chemoradiation?

The concept of bladder-sparing therapy for management of muscle-invasive bladder cancer has been increasingly viewed favorably by both patients and physicians over the last decade. Traditional bladder-sparing approaches have been termed tri-modality therapy (TMT) and incorporated aggressive cystoscopic resection of visible disease in the bladder followed by concurrent chemotherapy (with several regimens recognized as acceptable) and radiotherapy. Although no randomized trial of such approaches to the perceived “gold standard” of radical cystectomy with node dissection has been completed to date, large retrospective reviews suggest comparable long-term oncologic outcomes, with a significant percentage of patients retaining a functional bladd...