María Natalia Gandur Quiroga, Chief of the Division of Genitourinary Medical Oncology at the Angel H. Roffo Oncology Institute, shared on LinkedIn:
“One sentence kept coming back to me throughout IUCS26: The future of GU oncology is not simply treatment intensification. It is smarter integration.
Right treatment. Right sequence. Right patient. Right timing.
Across prostate, bladder and kidney cancer, many of the discussions in Guildford reflected the same fundamental shift: we are moving away from fixed treatment pathways and toward increasingly risk-adapted, response-adapted and biologically informed care.
The challenge is no longer simply whether we can intensify therapy.
It is deciding when intensification creates meaningful benefit — and when it creates unnecessary toxicity without enough added value.
Prostate cancer: from ‘give ADT‘ to ‘who needs what?‘
The discussion by Alison tree captured this evolution particularly well.
For decades, the systemic-treatment conversation in localized high-risk prostate cancer often centered on whether androgen deprivation therapy should accompany radiotherapy.
Today the questions are considerably more sophisticated:
- Who can avoid ADT?
- Who needs a short course?
- Who needs prolonged treatment?
- Who should receive AR-pathway intensification?
- And which patients derive enough absolute benefit to justify the long-term burden of systemic therapy?
STAMPEDE and ENZARAD have strengthened the case for intensification in selected higher-risk populations.
The perioperative space is evolving as well.
In PROTEUS, perioperative apalutamide plus ADT around radical prostatectomy improved pathological response measures compared with ADT alone, including higher pCR/MRD rates and fewer positive surgical margins, with an encouraging metastasis-free survival signal in the data presented.
But the key message is not: ‘More treatment for everyone.’
It is: Selective intensification for the patients most likely to benefit.
That distinction matters enormously.
Because every additional systemic intervention has consequences – metabolic, cardiovascular, sexual, cognitive, financial and quality-of-life related.
Precision must therefore include not only tumor biology, but the lived experience of the patient.
Bladder cancer: the systemic and local worlds are converging
Few areas of GU oncology illustrate integration more dramatically than muscle-invasive bladder cancer.
The perioperative landscape has changed rapidly.
NIAGARA demonstrated the benefit of integrating immunotherapy into perioperative cisplatin-based treatment.
And KEYNOTE-B15/EV-304 has further expanded the conversation by showing the potential of perioperative enfortumab vedotin plus pembrolizumab in cisplatin-eligible disease.
For cisplatin-ineligible patients, KEYNOTE-905/EV-303 showed a striking pathological complete response rate with perioperative EV + pembrolizumab compared with surgery alone, alongside event-free and overall-survival benefit.
These advances immediately generate a provocative next question: If systemic therapy can produce such deep responses, do all complete responders need immediate cystectomy?
That is where the discussions by Param Mariappan and Dr. Darren Poon became particularly important.
Bladder preservation is no longer simply a radiotherapy-versus-surgery discussion.
It is becoming an integrated strategy involving:
- maximal TURBT
- effective systemic treatment
- rigorous clinical restaging
- cystoscopy and biopsy
- imaging
- urine cytology
- ctDNA and utDNA
- molecular biomarkers
- definitive local therapy when response is inadequate
- and intensive surveillance in carefully selected responders.
But there is an essential caution. Pathological complete response and clinical complete response are not interchangeable.
Sampling error, treatment-related tissue changes, imaging limitations and interobserver variability still make response assessment imperfect.
That means the question is not simply: ‘Can we preserve the bladder?’
The real question is: ‘Can we identify, with sufficient certainty, the patient in whom bladder preservation is oncologically safe?’
That will be one of the defining research questions of the next phase of MIBC care.
Biomarkers must change decisions, not simply produce information
This same principle applies to biomarkers.
Its value lies in whether it answers a clinically relevant question.
In prostate cancer, we increasingly integrate:
- germline genetics
- somatic alterations
- genomic classifiers
- PSMA imaging
- ctDNA
- circulating tumor cells and evolving disease phenotype.
In renal cancer, ctDNA, KIM-1, CAIX, FAP, ROR2 and CD70 are expanding the biomarker landscape, while studies such as CARE-1 are asking whether biological stratification may help us choose between immune-based therapeutic strategies.
In urothelial cancer, the success of antibody-drug conjugates has made resistance biology increasingly important.
NECTIN-4, TROP-2, HER2 and FGFR alterations may help define distinct therapeutic vulnerabilities, while target heterogeneity and evolving resistance remind us that a biomarker measured once may not tell the whole story.
The future will likely depend less on static testing and more on longitudinal biological assessment.
Precision is also about knowing when not to intensify
One of the most valuable cultural changes in oncology is the growing recognition that precision treatment includes de-escalation.
A biomarker that identifies someone who safely needs less treatment may ultimately be as valuable as one that identifies a new drug target.
The same is true for clinical risk assessment.
Age alone should not determine therapy.
Frailty, physiological reserve, cognition, nutrition, comorbidities, polypharmacy, function and patient priorities may be far more relevant than chronological age.
And in advanced disease, treatment sequencing should be driven not only by what therapies are available, but by biology, prior exposure, disease phenotype, tolerability and individual goals.
What I took home from IUCS26
Across disease sites, one principle emerged repeatedly: Integration is becoming the real frontier of precision oncology.
Not simply:
local therapy or systemic therapy.
Surgery or radiotherapy.
Immunotherapy or targeted therapy.
ADC or chemotherapy.
Intensification or de-escalation.
The future is the intelligent combination of these tools around the biology of the disease and the priorities of the individual patient.
That requires better biomarkers.
Better response assessment.
Better multidisciplinary discussion.
And better evidence about who truly benefits.
The most sophisticated cancer care will not necessarily be the care that uses the most treatment.
It will be the care that uses exactly enough treatment, at exactly the right moment, for exactly the right patient.
That was, for me, one of the strongest messages of IUCS26.”
Other articles about IUCS26 on OncoDaily.