Editor’s Note: Bladder cancer is one of the most common malignant tumors among the Chinese population, with 75% of cases classified as non-muscle invasive bladder cancer (NMIBC), which has a high postoperative recurrence rate. What are the unmet diagnostic and treatment needs of NMIBC patients? Which research findings may change future clinical practice for NMIBC? During the recent CUA Annual Meeting, Urology Frontier invited Dr. Jeremy Teoh from The Chinese University of Hong Kong to discuss the current unmet needs in NMIBC, the factors influencing recurrence, and the latest research developments that could potentially change clinical practice.

1. What Unmet Clinical Needs Exist for NMIBC?

Dr. Jeremy Teoh: Although non-muscle invasive bladder cancer (NMIBC) is a curable disease, it has a high recurrence rate. On average, the recurrence rate within one year remains around 30% to 40%. We are still exploring different treatment combinations and new strategies to optimize treatment outcomes.

Additionally, some patients do not respond to standard Bacillus Calmette-Guérin (BCG) therapy. Traditionally, these patients may require radical cystectomy, but such a procedure can have multiple impacts on their quality of life. Thus, another unmet need is to develop bladder-preserving treatment options for high-risk patients, aiming to further improve their quality of life.

2. Based on Your Clinical Experience, What Factors Might Lead to NMIBC Recurrence?

Dr. Jeremy Teoh: The recurrence mechanisms of non-muscle invasive bladder cancer are quite complex from a clinical perspective. I think the following two points should be emphasized.

First, the surgery itself is crucial—whether the tumor can be completely removed. From the current data, even after transurethral resection of bladder tumor (TURBT), up to 30% of patients still have residual disease, meaning that these patients require a second TURBT to check for residual tumors. Our team has been thinking about how to optimize surgery to ensure complete tumor removal. We’ve also conducted numerous en bloc resection trials at our center to address this issue.

Second, for multifocal tumors, carcinoma in situ, and aggressive tumors, understanding their distinct biological characteristics is essential. In future clinical practice, exploring various adjuvant treatment strategies to control the biological progression of these tumors will likely be necessary.

3. At the Recent European Society for Medical Oncology (ESMO) Conference, Several NMIBC Research Results Were Announced. Which Ones Do You Think Might Soon Be Applied in Clinical Practice?

Dr. Jeremy Teoh: Recently, several NMIBC research results were released. I believe the research most likely to be applied in clinical practice is the Sunrise-1 study. This study used the TAR-200 intravesical drug delivery system, which can continuously release the chemotherapeutic agent gemcitabine. This treatment strategy primarily targets high-risk, BCG-unresponsive NMIBC patients, and the study found that TAR-200 achieved a complete response in about 83% of patients within one year. I think that as the data matures, this treatment may soon be approved for clinical use, benefiting more patients.

4. What Other Directions Are You and Your Team Exploring for NMIBC?

Dr. Jeremy Teoh: Currently, we are exploring multiple treatment directions. First, we are focusing on patient selection, using multiparametric evaluations, including MRI scans, urinary biomarkers, and treatment response predictions, to choose the most suitable treatment plans for patients.

Second, we are investigating the technique of en bloc resection. Our team published a randomized trial in European Urology, showing that en bloc resection can reduce the recurrence rate within one year. We are also conducting meta-analyses of individual patient data and building a global real-world data registry, which could impact clinical practice and guidelines.

Third, we are exploring how to address tumor heterogeneity. Precision medicine in cancer treatment has not been as successful as expected, partly due to tumor heterogeneity. Traditional molecular classification usually samples only a small part of the tumor, assuming it represents the entire tumor, but this may not be accurate. We are trying different approaches to more extensively evaluate the tumor in 3D, allowing us to classify molecular features and visualize the tumor’s heterogeneity. This could lead to more effective precision treatments in the future.

Dr. Jeremy Teoh Assistant Dean (External Affairs), Faculty of Medicine, The Chinese University of Hong Kong Associate Professor, Department of Urology, The Chinese University of Hong Kong Director, Urology Center, CUHK Medical Centre Director, Robotic Surgery Services, CUHK Medical Centre Visiting Professor, Medical University of Vienna Member, NMIBC Guidelines Panel, European Association of Urology (EAU) Member, Communication Committee, EAU Guidelines Office Consulting Editor, European Urology Deputy Editor, European Urology Oncology Member, Urothelial Carcinoma Working Group, Young Urologists of the EAU Chair, Scientific Program Committee, Société Internationale d’Urologie (SIU) Innovators Member, SIU Recipient of the 2021 SIU Innovators Award Recipient of the 2021 Hong Kong Ten Outstanding Young Persons Award Published over 400 peer-reviewed articles Secured over 80 million HKD in research funding