IBCG Risk Stratification Model Is Added to 2026 NCCN Guidelines for IR-NMIBC

The National Comprehensive Cancer Network (NCCN) has updated its Clinical Practice Guidelines in Oncology for bladder cancer to include the International Bladder Cancer Group (IBCG) 5-factor clinical risk stratification model for intermediate-risk non–muscle-invasive bladder cancer (NMIBC).^1,2

The updated guidelines now stratify patients with intermediate-risk NMIBC into 3 clinically actionable subgroups: lower risk (0 risk factors), intermediate risk (1 to 2 risk factors), and higher risk (≥3 risk factors).¹ The IBGC framework aims to offer oncologists clear guidance on how to aggressively treat individual patients by incorporating 5 clinically relevant risk factors: tumor multifocality, tumor size of at least 3 cm, early recurrence within 1 year, frequent recurrences (>1 per year), and prior failure of intravesical therapy. These factors were selected due to their established association with disease recurrence and progression, allowing oncologists to identify patients at greater risk of adverse outcomes within a category that has historically been managed with a one-size-fits-all approach.

“For decades, intermediate-risk bladder cancer has been a highly heterogeneous, catch-all category that left patients vulnerable to both over- and undertreatment,” Ashish M. Kamat, MD, MBBS, stated in a news release. “Through this framework, clinicians can safely de-intensify care for appropriate patients while ensuring that those with higher-risk features receive the adjuvant therapies they need. The NCCN’s adoption of this model represents an important step toward more precise and standardized care for bladder cancer patients.”

Kamat is the president of the International Bladder Cancer Group as well as an endowed professor, Wayne B. Duddlesten Sr. Professorship in Cancer Research, Department of Urology, Division of Surgery, and a tenured professor in the Department of Urology at the University of Texas MD Anderson Cancer Center in Houston.

How was the IBCG risk stratification model developed?

The IBCG risk stratification model was first published in 2014.³ A team of investigators led by Kamat analyzed clinical trials, meta-analyses, and clinical practice guidelines that examined intermediate-risk NMIBC as of September 2013. The authors considered the definition of intermediate-risk disease, patient outcomes, and guideline recommendations, as well as the limitations of the available literature and additional parameters that could be useful in guiding treatment decisions in this patient population.

The authors determined that patients with intermediate-risk NMIBC were a heterogeneous group of patients and proposed a management algorithm to assist in the comparison of therapies and outcomes that considers disease characteristics, timing and frequency of recurrence, and prior treatment.

In 2022, an update published in European Urology Oncology formally codified the scoring system.⁴ The update included progression on previous intravesical therapy as a distinct, independently scored risk factor and provided clarification for the boundaries of the intermediate-risk category by excluding all patients with high-grade disease.

What data have validated the IBCG risk stratification model?

A 2024 multicenter retrospective study stratified patients (n = 677) into IBCG intermediate-risk–low (n = 231), -intermediate (n = 364), and -high (n = 82) subgroups.⁵ Findings from the retrospective study revealed that patients in these respective subgroups experienced 1-year recurrent rates of 10.7% (95% CI, 7.7%-15.6%), 13.1% (95% CI, 9.9%-17.1%), and 33.5% (95% CI, 24.1%-45.2%). The respective 3-year recurrence rates were 29.5% (95% CI, 23.3%-37.1%), 36.9% (95% CI, 31.5%-42.8%), and 67.5% (95% CI, 55.7%-78.8%).

Patients in the intermediate (HR, 1.47; 95% CI, 1.08-2.01; P = .013) and high (HR, 3.36; 95% CI, 2.31-4.91; P < .001) subgroups experienced a significant difference in recurrence-free survival compared with the low subgroup. A significant difference in progression-free survival was also reported in the intermediate (HR, 2.09; 95% CI, 0.68-6.41; P = .2) and high (HR, 4.97; 95% CI, 1.45-17.01; P = .01) subgroups compared with the low subgroup.

“Intermediate-risk NMIBC has long needed a framework like this — one that gives [oncologists] the confidence to de-intensify care for patients who don’t need aggressive treatment, and to intensify it for those who do. Seeing it incorporated into the NCCN guidelines is deeply gratifying,” Wei Shen Tan, MD, PhD, FRCS, an IBCG member and an assistant professor of urology at the Yale School of Medicine in New Haven, Connecticut, added in the news release.¹

References

1. NCCN 2026 bladder cancer guidelines adopt IBCG risk stratification model for intermediate-risk NMIBC. News release. NCCN. March 24, 2026. Accessed March 25, 2026. https://www.knoxnews.com/press-release/story/161588/nccn-2026-bladder-cancer-guidelines-adopt-ibcg-risk-stratification-model-for-intermediate-risk-nmibc/
2. NCCN. Clinical Practice Guidelines in Oncology. Bladder cancer, Version 1.2026. March 16, 2026. Accessed March 26, 2026. https://www.nccn.org/professionals/physician_gls/pdf/bladder.pdf
3. Kamat AM, Witjes JA, Brausi M, et al. Defining and treating the spectrum of intermediate risk nonmuscle invasive bladder cancer. J Urol. 2014;192(2):305-315. doi:10.1016/j.juro.2014.02.2573
4. Tan WS, Steinberg G, Witjes JA, et al. Intermediate-risk non-muscle-invasive bladder cancer: updated consensus definition and management recommendations from the International Bladder Cancer Group. Eur Urol Oncol. 2022;5(5):505-516. doi:10.1016/j.euo.2022.05.005
5. Soria F, Rosazza M, Livoti S, et al. Clinical validation of the intermediate-risk non-muscle-invasive bladder cancer scoring system and substratification model proposed by the International Bladder Cancer Group: a multicenter Young Academic Urologists Urothelial Working Group collaboration. Eur Urol Oncol. 2024;7(6):1497-1503. doi:10.1016/j.euo.2024.06.004