Editor’s Note: The 2026 Pujiang Urological Oncology Academic Conference was held in Shanghai, bringing together experts from China and abroad to discuss standardized diagnosis and treatment, innovations in surgical techniques, and advances in precision medicine in urological oncology. In recent years, immunotherapy and antibody-drug conjugates (ADCs) have progressively moved from the treatment of advanced urothelial carcinoma (UC) into the perioperative setting, reshaping the overall treatment landscape of bladder cancer. Oncology Frontier – UroStream invited Professor Chunguang Ma of the Department of Urology, Fudan University Shanghai Cancer Center, for an interview to discuss changes in the landscape of adjuvant therapy for UC, the optimal timing and patient selection for adjuvant immunotherapy, future directions for ADC–immunotherapy combinations, and the integration of surgery with systemic therapy, sharing his clinical experience and perspectives on emerging developments.From “Performing High-Quality Surgery” to “Whole-Course Management”: A Shift in Perioperative Concepts
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In recent years, systemic therapy for urothelial carcinoma has increasingly moved into earlier stages of treatment. For urologists, the focus in the past was largely on performing high-quality surgery, whereas today they must also consider how perioperative systemic therapy can reduce the risks of recurrence and metastasis. Based on your clinical experience, how should we understand this shift in treatment philosophy? What changes has the incorporation of immunotherapy brought to postoperative management of high-risk patients?
Professor Chunguang Ma: Bladder cancer, particularly muscle-invasive bladder cancer (MIBC), should not always be viewed as a disease confined to the bladder. It has the potential to behave as a systemic disease. Some patients may already have micrometastatic disease that cannot be detected by conventional imaging before surgery, which is an important cause of postoperative recurrence and metastasis. Traditional chemotherapy can provide clinical benefit and reduce the risk of recurrence, but there remains room for further improvement.
Following the encouraging efficacy demonstrated by immunotherapy and ADCs in advanced disease, these strategies have progressively moved into the neoadjuvant, adjuvant, and broader perioperative settings for MIBC. Current evidence suggests that these approaches may improve survival and reduce the risks of recurrence and metastasis, contributing to the ongoing evolution of standard perioperative treatment.
Of course, comprehensive perioperative treatment is not appropriate for every patient. For individuals with lymph node involvement, locally advanced disease, or other high-risk features, postoperative adjuvant therapy or comprehensive perioperative treatment may provide additional benefit. Surgery primarily addresses the local tumor burden, whereas systemic therapy is needed to control potential micrometastatic disease. The key challenge going forward will be to accurately identify patients who are most likely to benefit while avoiding unnecessary treatment.
Precisely Identifying High-Risk Patients: Using ctDNA/MRD to Guide Selection for Adjuvant Therapy
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After radical surgery, patients have substantially different risks of recurrence, meaning that adjuvant therapy should not simply be viewed as adding another drug after surgery. In real-world clinical practice, how should we identify patients who truly require intensified adjuvant treatment? Beyond pathological stage and lymph node status, what additional markers may improve patient selection in the future?
Professor Chunguang Ma: According to current clinical guidelines, patients with pathological stage pT3–pT4 disease or lymph node involvement following radical cystectomy should generally be considered for postoperative adjuvant therapy, including adjuvant chemotherapy or immunotherapy. Patients who have received neoadjuvant chemotherapy but still have pathological stage pT2 or higher disease or lymph node involvement after surgery should also be considered for adjuvant immunotherapy. At present, risk assessment is still primarily based on traditional factors such as pathological stage and lymph node status.
In the future, circulating tumor DNA (ctDNA) and molecular residual disease (MRD) monitoring may further improve patient selection. Postoperative ctDNA positivity generally indicates a higher risk of recurrence and metastasis, and corresponding adjuvant treatment may improve outcomes. An increasing number of studies are evaluating the value of ctDNA in guiding postoperative adjuvant therapy, monitoring recurrence risk, and assessing treatment response.
This reflects the broader transition in oncology from stage-based treatment toward risk stratification, precision, and individualized care. As evidence continues to accumulate, we hope that ctDNA, MRD, and other biomarkers can be more systematically incorporated into clinical pathways and combined with pathological characteristics, imaging findings, and patients’ overall clinical status to establish a multidimensional decision-making framework.
Integrating Surgery and Systemic Therapy: Comprehensive Perioperative Treatment Through MDT
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As systemic therapies such as immunotherapy enter the perioperative setting, the role of urologists is also evolving. In addition to performing high-quality surgery, they need to participate in preoperative assessment, perioperative treatment planning, postoperative adjuvant therapy, and long-term follow-up. How should we redefine the relationship between surgery and systemic therapy today? How can MDT truly integrate high-quality surgery with high-quality perioperative treatment?
Professor Chunguang Ma: Cancer treatment involves multiple modalities, including surgery, radiotherapy, chemotherapy, immunotherapy, and targeted therapy. Because cancer has the potential to behave as a systemic disease, relying solely on local surgery or radiotherapy is often insufficient to achieve the best possible outcomes. Different treatment modalities therefore need to be integrated within a multidisciplinary team (MDT) framework.
For MIBC, the responsibilities of urologists are no longer limited to performing radical surgery. They should also participate in preoperative staging and risk assessment, perioperative treatment selection, postoperative adjuvant therapy, and long-term follow-up. High-quality surgery provides the foundation, while systemic therapy is used to control potential micrometastatic disease. The two should form a continuous treatment strategy around a common therapeutic goal.
Current evidence suggests that an integrated approach consisting of neoadjuvant systemic therapy, radical surgery, and postoperative adjuvant treatment may further improve survival. Future clinical studies should continue to explore the optimal combinations, sequencing, and patient populations for immunotherapy, ADCs, and other agents in combination with surgery, so that MDT becomes not merely a consultation model but a genuine mechanism for whole-course disease management.
Individualized Adjuvant Therapy: The Future of Molecular Classification and Biomarker-Guided Treatment
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Looking ahead, adjuvant treatment for UC may involve more therapeutic strategies and combinations. What do you consider the most promising directions for the future? Could molecular classification, MRD monitoring, or other biomarkers help us more accurately determine who needs treatment, which regimen should be selected, and how long treatment should continue, ultimately enabling truly individualized adjuvant therapy?
Professor Chunguang Ma: At present, postoperative adjuvant treatment for patients with locally advanced disease or lymph node involvement mainly consists of chemotherapy and immunotherapy, with adjuvant immunotherapy having demonstrated meaningful clinical benefit. However, some patients still develop recurrence and metastasis during long-term follow-up, indicating that there remains room to optimize current monotherapy approaches.
Drawing on experience from advanced UC, combination therapy may prove more effective than single-agent treatment. One promising direction is whether ADCs combined with immunotherapy can further improve outcomes in the adjuvant or broader perioperative setting. However, the potential benefits and risks of such strategies still need to be confirmed in prospective clinical trials.
At the same time, adjuvant treatment is not necessary or beneficial for every patient. Immunotherapy, ADCs, and combination regimens can all cause treatment-related adverse events, some of which may be serious. Therefore, true precision treatment is not simply about “adding treatment for high-risk patients”; it also requires accurately identifying who is most likely to benefit, who can safely avoid overtreatment, and how long therapy should continue. ctDNA, MRD monitoring, and other biomarkers may become important tools in this process. Combined with molecular classification, pathological characteristics, and clinical factors, they may help individualize the selection of treatment populations, regimens, and treatment duration.
Summary
Professor Chunguang Ma’s discussion provides a systematic overview of the evolution of adjuvant treatment for urothelial carcinoma from the chemotherapy era toward the immunotherapy era. Adjuvant immunotherapy has become an important standard treatment option for high-risk patients after surgery, while ADC–immunotherapy combinations are being explored in earlier and perioperative settings.
In real-world clinical practice, initiation of adjuvant immunotherapy requires careful consideration of postoperative recovery, comorbidities, and the appropriate treatment window. Biomarkers such as ctDNA and MRD may further facilitate the precise identification of high-risk patients. Integrating high-quality surgical treatment with systemic therapy and implementing MDT-based whole-course management will be an important pathway toward improving long-term outcomes for patients with muscle-invasive bladder cancer.
Professor Chunguang Ma
Fudan University Shanghai Cancer Center
