Australian Practical Guide on the Management of Muscle-Invasive Bladder Cancer

Muscle-invasive bladder cancer presents a complex clinical challenge in Australia, where survival outcomes lag behind those in other high-income nations. Radical cystectomy remains the most frequently used curative approach. This review highlights a significant shift in the Australian landscape, with neoadjuvant chemotherapy uptake increasing from historic lows to over 60% according to recent registry data. Clinical unsuitability for cisplatin use and other factors, such as geographic disparities in access to multidisciplinary care, continue to be barriers to the more consistent use of perioperative systemic therapy. Emerging data from landmark trials, such as NIAGARA, KEYNOTE-905, and KEYNOTE-B15, are ushering in a new era of perioperative immunotherapy and antibody-drug conjugates, offering hope for more effective and personalized treatment pathways. Bladder-sparing trimodality therapy is recognized as an underutilized option that can provide good quality of life and oncologic outcomes. Integration of precision medicine, including molecular subtyping and ctDNA monitoring, optimization of surgical and other expertise, and establishment of national optimal care pathways will be essential for further improvement of outcomes. Australian clinicians must bridge the gap between the latest evidence and local reimbursement challenges to standardize care, reduce treatment-related morbidity, and improve long-term survivorship for patients with bladder cancer.