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Aligned Care in Bladder Cancer - Module 1: High-Risk NMIBC - Treatment Escalation Decisions

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Description

This program is supported by an independent education grant from MSD. This online education program has been designed solely for healthcare professionals in the US. The content is not intended for healthcare professionals in any other country.

This is Module 1 of a three-part on-demand series.

Join leading bladder cancer experts Dr. Petros Grivas and Dr. Benjamin Garmezy for this accredited online teaching session. Using three progressive, case-based role-play scenarios, this session explores the "ideal vs. real" complexities of managing bladder cancer across diverse practice environments.

By adopting specific hospital, community, and rural perspectives, the faculty will illustrate how to translate diagnostic findings into guideline-aligned treatment decisions despite real-world system constraints. Participants will gain practical insights into navigating resource limitations, strengthening multidisciplinary care coordination, and implementing escalation pathways for NMIBC, MIBC, and metastatic disease to ensure consistent, high-quality care in every setting.

Credits: AMA PRA Category 1 Credits™ (0.25.00 hours)

Session Overview

Navigating High-Risk NMIBC Escalation: Contrast guideline-ideal TURBT and BCG timing with the practical realities of rural care, focusing on safe treatment adaptations when pathology or resection access is limited.
Preserving Curative Intent in MIBC: Identify strategies to maintain the cisplatin-to-cystectomy sequence despite systemic barriers, including imaging delays, surgical access gaps, and patient travel constraints.
Systemic Therapy & Referral Triggers: Define clear "treat here vs. refer now" criteria for advanced urothelial carcinoma to manage monitoring logistics and follow-up care across diverse clinical settings.

Who Should Attend?

This program is designed for healthcare professionals in the US, directly involved in diagnosing, staging, and managing bladder cancer and making treatment-planning decisions across community, rural, and hospital settings, including:

Urologists (generalists, community urologists, and academic specialists)
Medical Oncologists involved in bladder cancer management
Advanced Practice Providers (nurse practitioners, physician associates) in urology and oncology
Urology Nurses and Oncology Nurses
Primary Care Clinicians in community or rural settings who participate in referral decisions
Allied Health Professionals supporting bladder cancer coordination and follow-up

Faculty

Petros Grivas, MD, PhD is an oncologist with expertise in treating genitourinary cancers such as bladder cancer, prostate cancer and testicular cancer. His clinical research helped lead to FDA approval of new drugs to treat the most common type of bladder cancer. Dr. Grivas currently leads clinical trials that investigate the use of checkpoint inhibitors. These immunotherapy drugs release the brakes on a patient’s immune system and help it mount a better response to cancer.

Benjamin Garmezy, MD is a board-certified medical oncologist and the Associate Director of Genitourinary Research at Sarah Cannon Research Institute (SCRI). With a deep clinical interest in prostate, kidney, bladder, and testicular cancers, he oversees the development of novel investigational therapies. A frequent faculty member at major international congresses including ASCO and ESMO, Dr. Garmezy has published extensively on clinical trial design and has authored over 50 abstracts focused on advancing the standard of care in GU oncology.

Continuing Education Information

Commercial support: This activity received monetary support through an independent education grant from MSD.

This continuing education activity will be provided by AffinityCE and MedAll. This activity will provide continuing education credit for physicians. A statement of participation is available to other attendees.

Faculty Disclosure Statement / Conflict of Interest

Petros Grivas, MD has disclosed financial interests or relationships within the past 24 months with the following ineligible companies: Consulting for MSD, BMS, AstraZeneca, EMD Serono, Pfizer, Janssen, Roche, Astellas Pharma, Gilead Sciences, Strata Oncology AbbVie, Bicycle Therapeutics, Replimune, Daiichi Sankyo, Foundation Medicine, Eli Lilly, Urogen, Tyra, Natera; Research funding paid to institution EMD Serono, Acrivon Therapeutics, ALX Oncology, MSD, Gilead Sciences, Genentech. These disclosures are made in accordance with ACCME standards to ensure transparency and objectivity in continuing education. Dr. Grivas may reference any unlabeled or unapproved uses of products during the presentation. He will disclose to the audience when this discussion takes place.

Benjamin Garmezy, MD has disclosed financial interests or relationships within the past 24 months with the following ineligible companies: Consulting for Adaptimmune, Adicent Therapeutics, AIQ Global, Amgen, AstraZeneca, Bayer, Bicycle Tx, BioNTech, Bristol-Myers Squibb, Eisai, EMD Serono, Exelixis, Genentech/Roche, GlaxoSmithKline, Janssen, Merck, Monte Rosa Therapeutics, Novartis, Onviv, Pfizer, Rondo Therapeutics, Seagen, Specialty Networks, Takeda Pharmaceuticals, Xencor; Research funding paid to institution Abbvie, Accutar Biotechnology, Adcentrx Therapeutics, Adicet Therapeutics, Amgen, Arcus Biosciences, Arvinas, AstraZeneca, Avenzo Therapeutics, AVEO Oncology, Bicycle Therapeutics, Bristol-Myers Squibb, CRISPR Therapeutics, Daiichi Sankyo, Eikon Therapeutics, Exelixis, Roche/Genentech, Flare Therapeutics, GlaxoSmithKline, Halda Therapeutics, Harbour BioMed, HiberCell, IDEAYA Biosciences, Incyte, Janssen, Janux Therapeutics, Jubilant Therapeutics, Kineta, Kinnate BioPharma, Loxo, Merck, Mink Therapeutics, Novartis, Nuvation Bio, Pfizer, Profound Bio, Rise Therapeutics, Rondo Therapeutics, Takeda Therapeutics, Teon Therapeutics, TMUNITY Therapeutics, Xencor, Zenshine. These disclosures are made in accordance with ACCME standards to ensure transparency and objectivity in continuing education. Dr Garmezy does not intend to discuss non-FDA uses of drug products and/or devices.

AffinityCE staff, MedAll staff, as well as planners and reviewers, have no relevant financial relationships with ineligible companies to disclose.

Mitigation of Relevant Financial Relationships

AffinityCE adheres to the ACCME’s Standards for Integrity and Independence in Accredited Continuing Education. Any individuals in a position to control the content of a CME activity, including faculty, planners, reviewers, or others, are required to disclose all relevant financial relationships with ineligible companies. Relevant financial relationships were mitigated by the peer review of content by non-conflicted reviewers prior to the commencement of the program.

Activity Accreditation for Health Professions

Physicians

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of AffinityCE and MedAll. AffinityCE is accredited by the ACCME to provide continuing medical education for physicians.

AffinityCE designates this enduring activity for a maximum of 0.25 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Physician Assistants

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of AffinityCE and MedAll. AffinityCE is accredited by the ACCME to provide continuing medical education for physicians.

AffinityCE designates this enduring activity for a maximum of 0.25 AMA PRA Category 1 Credits™. Physician assistants should claim only the credit commensurate with the extent of their participation in the activity.

Nurse Practitioners

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of AffinityCE and MedAll. AffinityCE is accredited by the ACCME to provide continuing medical education for physicians.

AffinityCE designates this enduring activity for a maximum of 0.25 AMA PRA Category 1 Credits™. Nurse practitioners should claim only the credit commensurate with the extent of their participation in the activity.

Nurses & Other Professionals

All other health care professionals completing this continuing education activity will be issued a statement of participation indicating the number of hours of continuing education credit. This may be used for professional education CE credit. Please consult your accrediting organization or licensing board for their acceptance of this CE activity.

System Requirements

Mobile device (e.g., large-format smart phone; laptop or tablet computer) or desktop computer with a video display of at least 1024 × 768 pixels at 24-bit color depth, capable of connecting to the Internet at broadband or faster speeds, with a current version Internet browser and popular document viewing software (e.g., Microsoft Office, PDF viewer, image viewer) installed. Support for streaming or downloadable audio-visual materials (e.g., streaming MP4, MP3 audio) in hardware and software may be required to view, review, or participate in portions of the program.

Unapproved and/or off-label use disclosure

AffinityCE/MedAll requires CE faculty to disclose to the participants:

When products or procedures being discussed are off-label, unlabeled, experimental, and/or investigational (not US Food and Drug Administration [FDA] approved); and
Any limitations on the information presented, such as data that are preliminary or that represent ongoing research, interim analyses, and/or unsupported opinion.

CME Inquiries

For all CME policy-related inquiries, please contact us at ce@affinityced.com.

Participation Costs

There is no cost to participate in this program.

Launch and Expiration Date: 25 June 2026 – 23 December 2027

Estimated time to complete this activity: 15 minutes

Disclaimer

This activity is intended for educational purposes only and does not establish a standard of care or replace clinical judgment. Any therapeutic or diagnostic strategies discussed must be evaluated in the context of each patient’s clinical circumstances, risks, and current evidence.

Learners should consult authoritative clinical guidelines and approved product information when considering treatment decisions.

All materials are used with permission. The views expressed are those of the faculty and do not necessarily reflect those of the accredited providers, MedAll, or any supporters.

Content is accurate as of the date of release.

Learning objectives

Upon completion of this activity, participants should be better able to:

Interpret key diagnostic and prognostic markers, including pathology, imaging, and clinical risk factors, to support risk assessment in diverse care settings.
Apply diagnostic findings to determine when to escalate care, refer, or adjust treatment planning based on available local resources.
Design and implement guideline-aligned treatment pathways for high-risk NMIBC, MIBC, and metastatic disease, accounting for workflow and access challenges in community and rural practices.
Implement practical strategies to navigate resource limitations and strengthen care coordination to support consistent bladder cancer management.

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Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hello everybody, and you're very warmly welcome to this MEO Educational program. This is the first time you're joining a Medall program and you're especially welcome. Before we begin, it's important that we share our disclosures with you, uh, and these are disclosures for, uh, consulting, research funding, uh, etc. and you will find that in that slide. Now, I want to focus your attention on the learning objectives for today's sessions including uh how we can interpret key diagnostic and prognostic biomarkers including pathology, imaging, and clinical risk factors to support risk assessment at diverse care settings. We also want to, uh, after completing this important activity, uh, to see if we're able to apply diagnostic findings to determine when to escalate care, refer, or adjust treatment planning based on available local resources. We also want to design and implement guideline-aligned treatment pathways for high-risk, non-muscle invasive, mass invasive bladder cancer, and metastatic eurothelial carcinoma, accounting for workflow and access challenges in community and rural practice settings. Last but not least, another objective is to implement practical strategies to navigate the resource limitations and strengthen care coordination to support consistent bladder cancer management. With that, uh, we're going to embark and start our, uh, first, uh, uh, uh, discussion point today, uh, which is about non-muscle invasive bladder cancer, and I'm going to start, uh, by discussing some details and I'm going to also, uh, uh, of course, let Doctor Garmese take it from there. I want to start by, uh, uh, setting the stage and putting the, uh, framework about non-muscle invasive bladder. Cancer, uh, many patients called it more superficial than the more deeper muscle-based bladder cancer, and that's an important distinction with, uh, significant differences in terms of, uh, uh, diagnostic, uh, states and management and of course prognosis. So in this risk gratification slide, we see how we stratify the risk, uh, for non-muscle invasive bladder cancer in terms of, uh, low intermittent high. Risk and there are certain criteria. Our colleagues and friends in urology are those who actually make this diagnosis, manage those patients in the most part, and they can stratify the risk based on the grade of disease, uh, based on the size of the tumor focality, uh, and recurrence pattern, presence of carcinoma in situ, left vascular invasion, histo subtype, all those factors can claim the risk certification for this cancer. And if we move across, uh, you know, the different risk factors here, the management is also different. So that slide is complicated, but just to give you a flavor that, uh, low risk, intermediate risk, and high risk non muscle-based bladder cancer are being managed differently. Uh, and of course if we think about, uh, how can we risk certify even further, we have criteria from the International Bladder Cancer Group, for example, looking at the number of tumors, the time of recurrence, less than a year from diagnosis, the frequency of recurrence. If it's more than 1 recurrence per year, the tumor size, if it's more than 30 centimeters or failure of prior intravescal treatment, or those are uh negative prognostic factors and can influence again, uh, risk certification and management and you see in the lower part of the slide, what are the different management options in patients with no extra risk factor, 1 to 2 risk factors, or 3 or higher risk factors. Again, just to give you a flavor and I want to say that PURBT translate to bladder tumor resection is so important. In the diagnosis, in staging, uh, and of course, uh, insights into the histology subtype presence or not, whether it's carcinoma in situ, left vascular invasion, so very important to have tissue in that decision making, uh, for a therapy and of course, again, as I mentioned, recertification and prognosis. Of course, recurrence and progression are the main concerns when we have non-muscle invasive bladder cancer and you see, uh, the risk of recurrence and progression, uh, of course, depends on the grade and the state of the tumor. Grade is low grade or high grade. High grade is, of course, has higher risk of recurrence and progression and the states, you know, front muscle-based bladder cancer is at, at CIS carcinoma in situ only. TA, which is a non-invasive papillary tumor, or T1, which means papillary tumor invading the lamina propria, but not the muscular dy propria. It's not muscle invasive. And of course, uh, if you have a higher stage like T1, you have a higher chance of recurrence and progression. You see that there is a chance of, uh, um, you know, further progression to muscle invasive disease. For example, 50%, uh, within. 3 years, uh, uh, if you have a T1 tumor to go to T2. Uh, so again, uh, it's important to have the states, uh, and the grade and of course all the other risk factors, uh, uh, assessed. And I think it's important to know that carcinoma in situ is CIS is by definition a high-risk feature along with level vascular invasion and the presence of histology variants or subtypes. Uh, I want to also point out that, uh, it's very common practice. And also a slide in a second, that when you have a T1 and sometimes a high grade TA, uh, you need to redisect again to make sure you're not missing a T2, a mass invasive tumor component. Recurrence and progression again, uh, uh, depends on multiple factors, uh, focality, number of recurrences, the size of the tumor, the grade, carcinoma, and xiety presence or not, uh, and again, all those, uh, factors, uh, to a different degree may influence the risk of recurrence and progression. What can we do about this? Of course, uh, the neurologists, uh, are experts and they want to optimize cystoscopy, and that's important because now we have enhanced cystoscopy, uh, narrow band imaging, blue light are some examples of that. Of course, we need to get the staging right, so accurate staging is important. So high quality URBT, which is transurethral bladed tumor resection, is very important and now we're starting to see incorporation of. useful biomarkers, uh, as we get more data and better technology, uh, we're using more biomarkers, uh, in clinical practice in that regard. And of course, the other goal is to identify failures early and offer radical cystectomy with pelvic lymph node dissection when indicated. So, I just mentioned that, uh, our colleagues in urology mentioned that quality of TURBT matters. So it's very important to have an experienced urologist who has done many TUR. RBTs, uh, I think it's important to have an optimal resection of the tumor. Uh, sometimes they have again different techniques, uh, and, and of course, the goal is to, uh, depending on the setting and whether it's feasible or not, uh, to remove, um, uh, the entire tumor if it's possible, of course, as I mentioned, especially if there is a plan for, uh, blood preservation down the road. Uh, and, uh, again, the, the, uh, technique matters, quality matters, and the experience matters. Uh, I, I talked about resection, as I mentioned, uh, if you have a, uh, high grade T1 and sometimes TA, um, uh, neurologist resect because you do not want to miss a T2, a muscle invasive component. Very important, uh, in, in terms of resection because you may actually understate even if you do not, uh, uh, I think it's T2, sometimes it may be. Two states, uh, uh, nearby. And if you have Muscat problem in the specimen of the TURBT there's about 20% chance of understaging. Uh, and also if you miss, uh, or you, if you lack uh Musca propria in the TURBT specimen, uh, that actually can increase the risk of understaging to up to 50%. So again, reresection is very important in that setting. So, uh, I want to also make the point here, uh, about urinary biomarkers that there are many that are under clinical trial testing, uh, and of course the goal is to, uh, improve upon cystoscopy and urine cytology. Urocytology can detect a high-grade urothytic carcinoma, but it's not very sensitive, can miss, uh, more than 20% of high grade disease, and, uh, uh, as I mentioned before, uh, it's, uh, urine cytology is not a good test for low-grade disease, so it's important. And again to have uh um uh an improvement in that regard uh through novel biomarkers and of course this is a human cytology takes some time to go through the preparation and, uh, pathology review so it's not a point of care test. Uh, and this is uh a snapshot from the uh AUA American Urology Association guidelines. Uh, this is urine biomarkers after diagnosis of bladder cancer. Uh, this is just to see that a lot of expert opinion here, um, and, uh. That tells us that we still need more data. Uh, we need more trials, uh, to give us, uh, more, uh, data points about clinical utility and in surveillance of non-muscular invasive bladder cancer, a clinician should not use urinary biomarkers, uh, in place of cystoscopy. Cystoscopy still has a major role. There are scenarios where you can potentially do cystoscopy less frequently, uh, and use urinary biomarkers in specific clinical scenarios based on available data. These are just uh uh uh some of examples of uh urinary biomarkers and here specifically, uh, biomarkers that uh seem to be approved. Uh, you see here on the left, the name of the biomarker and then the performance characteristics on the right, sensitivity and specificity. Of course, uh those performance characteristics can vary per assay and of course per study. There are other, uh, uh, promising biomarkers not approved yet, but, uh, interesting for the future. You see here some DNA based, RNA based and protein-based. I just want to uh give some uh highlight here about the performance characteristics. As I mentioned, uh, a lot of data are coming up soon, uh, exploring those, uh, DNA RNA proba biomarkers in, uh, a plethora of clinical trials.