Recent clinical evidence highlights three critical considerations for oncologists evaluating perioperative immunotherapy in muscle-invasive bladder cancer. First, the dual mechanism—enfortumab vedotin’s direct Nectin-4 targeting combined with pembrolizumab’s PD-1 checkpoint inhibition—simultaneously attacks tumour cells and activates the immune system, addressing complementary pathways often resistant to single-agent approaches.
Second, perioperative timing proves crucial: neoadjuvant administration primes immune responses before surgical resection, while adjuvant therapy maintains anti-tumour immunity during the critical post-operative window. This sequencing optimizes both local tumour control and systemic disease prevention.
Third, multidisciplinary monitoring for immune-related toxicities is non-negotiable. Adverse event management requires coordinated care between surgical oncologists, medical oncologists, and supporting specialties. Careful patient selection and toxicity surveillance protocols are essential prerequisites for safe implementation.
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