Dr Merrill on Selecting Patients for BCG Plus Durvalumab in High-Risk NMIBC

“For BCG and durvalumab, I would consider looking at that combination therapy in your high-risk patients.”

Suzanne B. Merrill, MD, FACS, a urologic oncologist and bladder cancer and advanced therapeutics regional leader at Colorado Urology, discussed considerations for selecting BCG plus durvalumab (Imfinzi) in patients with BCG-naive, high-risk non-muscle-invasive bladder cancer (NMIBC).

Merrill explained that the availability of combination treatment raises questions about which patients need intensification beyond BCG alone. She highlighted subgroup analyses from the phase 3 POTOMAC trial (NCT03528694) presented at the 2026 ESMO Congress, noting that patients with high-grade T1 disease appeared to experience greater benefit than the overall BCG-naive, high-risk study population. In her view, these findings could potentially support considering whether this subgroup represents a population for whom an intensified approach may be particularly relevant.

However, Merrill emphasized that identifying higher-risk disease is only one component of treatment selection, noting that clinicians must also determine whether the individual patient wants additional treatment and understand the potential additional adverse effects (AEs) of adding systemic therapy to intravesical BCG. A discussion about intensification should therefore include the possibility of increased AEs and the patient’s willingness to accept the increase, she said.

Merrill identified several clinical and pathological features that may inform these conversations, including high-grade T1 disease with lymphovascular invasion, variant histology, or persistent high-grade T1 disease identified during repeat transurethral resection. She described a patient with these concerning features who strongly prefers bladder preservation as someone for whom clinicians might consider an intensive combination approach.

She presented these factors as considerations for individualized selection, and acknowledged that additional questions remain about how best to incorporate the combination into practice and which patients should receive treatment beyond BCG. Ultimately, Merrill encouraged clinicians to evaluate both disease characteristics and patient preferences when considering BCG plus durvalumab. For selected patients with high-risk NMIBC, combination therapy may warrant discussion, provided patients understand the additional risk of AEs.