ctDNA: Transforming Adjuvant Therapy in Bladder Cancer

The IMvigor011 trial suggests postoperative circulating tumor DNA (ctDNA) testing can meaningfully guide adjuvant immunotherapy decisions after cystectomy.

Compared with clinicopathologic selection alone, the ctDNA-guided pathway in IMvigor011 spared many persistently molecularly negative patients from routine adjuvant therapy while directing intensified treatment to ctDNA-positive patients.

Median follow-up was approximately 22 months; patients who remained ctDNA-negative after surgery showed a low recurrence signal during that interval, supporting a de‑escalation approach for these molecularly low‑risk individuals and reframing how adjuvant risk stratification is constructed.

ctDNA-positive patients randomized to adjuvant atezolizumab experienced an approximate 36% lower risk of disease recurrence and a 41% lower risk of death versus control (median follow-up ~22 months).