For persistent localized muscle-invasive bladder cancer following chemoradiation in patients who are not surgical candidates, what is an appropriate next therapy?

For this situation, optimal therapy is unclear. However, assuming the patient did not achieve clinical CR or recurred within a year, following maximal TURBT (which can achieve remissions in up to 15% of untreated patients), systemic therapy may be considered while tailoring therapy based on previous therapy, patient preferences and genomic profiling. In patients who received concurrent cisplatin with radiation, I recommend pembrolizumab in general, although erdafitinib may be reasonable in those...

I think Dr. @Dr. First Last's approach is very reasonable, but I would add one other consideration -- it is worth checking on exactly what chemoradiation was used -- some practitioners reduce doses or truncate the regimen, and that can lead to failure. Depending on radiation dose when failure is recognized, salvage cystectomy may be worth re-considering ---- "not surgical candidate" can mean many things, and sometimes the clinician who favors chemorads does a poor job of discussing the strengths...