Current and Future Landscape of Perioperative Treatment for Muscle-Invasive Bladder Cancer

SIMPLE SUMMARY: The risk of recurrence of patients with localized muscle-invasive bladder carcinoma (MIBC) is still high. The outcomes of surgery and perioperative therapy are limited, and several patients are not candidates for neoadjuvant chemotherapy and have no further alternatives available. In recent years, many drugs have been evaluated in the metastatic setting. This review summarizes the evidence of perioperative treatment with these new drugs for MIBC, emphasizing immunotherapy and targeted agents. ABSTRACT: Cisplatin-based neoadjuvant chemotherapy followed by radical cystectomy is the current standard of care for muscle-invasive bladder cancer (MIBC). However, less than half of patients are candidates for this treatment, and 50% will develop metastatic disease. Adjuvant chemotherapy could be offered if neoadjuvant treatment has not been administered for suitable patients. It is important to reduce the risk of systemic recurrence and improve the prognosis of localized MIBC. Systemic therapy for metastatic urothelial carcinoma has evolved in recent years. Immune checkpoint inhibitors and targeted agents, such as antibody-drug conjugates or FGFR inhibitors, are new therapeutic alternatives and have shown their benefit in advanced disease. Currently, several clinical trials are investigating the role of these drugs, as monotherapy and in combination with chemotherapy, in the neoadjuvant and adjuvant settings with promising outcomes. In addition, the development of predictive biomarkers could predict responses to neoadjuvant therapies.