Utility of ctDNA, Overcoming Barriers to Multidisciplinary Care in Community, Academic Settings

A virtual roundtable, hosted by Dr. Petros Grivas of Fred Hutchinson Cancer Center, contextualized the latest bladder cancer research updates and trials of relevancy to come out of the 2025 American Society of Clinical Oncology Genitourinary Cancers Symposium. Dr. Grivas was joined by Drs. Guru Sonpavde, Elizabeth Plimack, Christopher Wallis, Terence Friedlander, and Matthew Galsky.

In the fifth segment of the roundtable, the panel considers the evolving role of ctDNA in guiding adjuvant therapy decisions, highlighting ongoing studies like IMvigor011 and the MODERN trial, which stratifies post-cystectomy patients based on ctDNA status. They also emphasize the importance of multidisciplinary collaboration in bladder cancer care, advocating for real-time coordination in academic centers and strong communication in community settings to ensure timely and effective treatment.

View the next segment on Pioneering Advances in Bladder Cancer: New Drug Classes, Biomarkers, and Treatment Models.

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Dr. Grivas: Dr. Friedlander, I am looking forward to seeing ctDNA data incorporated into the analysis that Dr. Galsky so effectively presented at ASCO GU. Are you currently using ctDNA to guide decisions regarding adjuvant therapy, or do you believe it is not yet ready for clinical implementation?

Dr. Friedlander: At this moment, I am not using ctDNA to determine whether to administer adjuvant therapy. I am not sure we are quite at that stage yet. I think of ctDNA almost like PSA, serving as a biomarker for disease recurrence after surgery. We know that patients with positive ctDNA following surgery almost universally experience relapse, usually within just a few months. This can help in planning subsequent therapies.

In the IMvigor neoadjuvant studies, ctDNA appeared to be a useful tool for determining who should receive adjuvant therapy. The ongoing IMvigor011 study is exploring this further. Dr. Galsky, you have a study that is also utilizing cell-free DNA to help guide therapy selection and assign the most appropriate treatment to each patient. You might be able to elaborate on that.

Dr. Galsky: Certainly. The MODERN study is currently enrolling patients following radical cystectomy who have high-risk pathological features, similar to those in CheckMate 274 and other recent studies. Patients undergo ctDNA testing, and if ctDNA is detectable, they are randomized to receive either adjuvant nivolumab or adjuvant nivolumab plus relatlimab. If ctDNA is undetectable, patients are randomized to adjuvant nivolumab or surveillance, with the option to initiate nivolumab if their ctDNA status converts from undetectable to detectable.

Dr. Grivas: It is important to highlight the MODERN trial. Great work, Dr. Galsky, on this very important study, which aims to address key clinical questions. The MODERN trial, along with IMvigor011, will help determine the predictive value of ctDNA and establish whether it has clinical utility in this setting.

This has been a great discussion. I would like to take this opportunity to ask Dr. Wallis about the value of a multidisciplinary approach. We all appreciate the benefits of multidisciplinary clinics. Can you discuss how this model can be optimized across different practice settings? There are inherent challenges, particularly in community practices, related to co-location and access to specialists such as medical oncologists, radiation oncologists, and urologists. What are your thoughts on how to implement and improve multidisciplinary collaboration?

Dr. Chris Wallis: Absolutely. When considering multidisciplinary care, there are two primary models: synchronous and asynchronous collaboration.

We are fortunate in Toronto, as well as in many other academic institutions, to have synchronous multidisciplinary clinics. For newly diagnosed muscle-invasive bladder cancer, patients in Toronto are seen in a clinic staffed by a urologic oncologist, a radiation oncologist, and a medical oncologist. All three specialties are present during the visit, allowing for real-time review of updated cystoscopy results, imaging, and pathology. Together, they formulate a treatment plan and discuss it with the patient. This model is ideal, but it is not always feasible in every setting.

In community-based or private practice settings, synchronous multidisciplinary clinics may not be practical. In these cases, the key to successful multidisciplinary care is proactive communication between physicians. It is not sufficient to rely solely on chart notes and expect the next provider to review them independently. When operating in a staggered, asynchronous manner, direct communication among specialists is essential.

Even in multidisciplinary clinics, coordination is critical, particularly when transitioning from neoadjuvant therapy to surgery. Effective communication is necessary to monitor treatment progress, assess for potential early discontinuation, evaluate interval scans, and secure appropriate operating room dates. These details help ensure a seamless patient care pathway.

Delays in proceeding to upfront cystectomy can lead to worse outcomes, as can delays in transitioning from neoadjuvant therapy to definitive treatment. Therefore, maintaining consistent communication and coordination is vital to delivering effective multidisciplinary care. While integrated clinics make this process easier, it is still achievable in other settings as long as there is structured and intentional collaboration.

Dr. Grivas: Excellent points. You articulated this very well, and I completely agree. Multidisciplinary collaboration is invaluable, and communication remains the key to ensuring optimal patient care.