Urology: Muscle-invasive bladder neoadjuvant chemotherapy

Why E is correct

For a cisplatin-eligible patient being worked up for radical cystectomy, the NIAGARA trial showed that adding perioperative durvalumab (neoadjuvant durvalumab with gemcitabine-cisplatin, then adjuvant durvalumab) to the cystectomy pathway significantly improved event-free and overall survival versus neoadjuvant chemotherapy alone (24-month event-free survival 67.8% vs 59.8%; hazard ratio 0.68). NICE TA1138 (2026) recommends this regimen. Neoadjuvant cisplatin combination chemotherapy alone was the previous standard under NICE NG2, but is now superseded for the cystectomy-bound patient. The durvalumab regimen was studied on the cystectomy pathway, not with bladder-preserving chemoradiotherapy.

And why the others are not

• ASingle-agent neoadjuvant pembrolizumab is not the standard; the evidence is for perioperative durvalumab combined with cisplatin-based chemotherapy.
• BSingle-agent carboplatin is not an adequate neoadjuvant regimen; cisplatin-based combination chemotherapy (now with perioperative durvalumab) is standard for cisplatin-eligible patients.
• CProceeding straight to cystectomy forgoes the survival benefit of perioperative systemic therapy in a fit, cisplatin-eligible patient.
• DNeoadjuvant cisplatin combination chemotherapy alone was the former NICE NG2 standard, but NIAGARA and NICE TA1138 have added perioperative durvalumab for the cystectomy pathway, so this is no longer the single best answer.

Source NICE NG2 — Bladder cancer: diagnosis and management — National Institute for Health and Care Excellence. Bladder cancer: diagnosis and management. NICE guideline NG2. Published 25/02/2015.