Would you give immunotherapy after neoadjuvant gem-cis for bladder cancer if cystectomy is being postponed for months due to non-autoimmune/unrelated comorbidities?

Delay in cystectomy regardless of the use of neoadjuvant chemotherapy is associated with compromised survival outcomes (Chu et al., PMID 30840335) and if a patient receives neoadjuvant chemotherapy and is unable to undergo cystectomy for months due to comorbidities, there is no clear data to support the use of immunotherapy as a bridge to surgery. For such a patient, trimodality therapy would be a reasonable alternative to radical cystectomy with data suggesting comparable outcomes to cystectomy in appropriately selected patients (Zlotta et al., PMID 37187202).

If I’m understanding the question correctly, a patient is not having cystectomy due to comorbidity. I think more information would be helpful, but in general, radical cystectomy is not the only option for these patients. It’s important to remember that TMT is a category 1 NCCN recommendation for MIBC, and this does not need to be biased towards the elderly and frail. A recent high-quality meta-analysis showed that bladder preservation with TMT is at least non-inferior to surgery. Of course, a randomized study would be preferred but this was cut short in the past due to poor accrual. There is no evidence to give IO as a bridge to RC. SWOG 1806 had fully accrued but has not been read out, but this will answer the question of IO (atezolizumab)...