The National Comprehensive Cancer Network (NCCN) has updated its bladder cancer guidelines to recommend considering circulating tumor DNA (ctDNA) molecular residual disease (MRD) testing after bladder removal surgery for patients with muscle-invasive bladder cancer (MIBC). This is the first time the NCCN has recognized ctDNA-MRD as both a prognostic and predictive biomarker for this disease.
The guideline recommends using FDA-approved, personalized ctDNA tests to help identify patients at higher risk of recurrence and guide decisions about adjuvant immunotherapy in those who have not previously received immune checkpoint inhibitors.
The recommendation is based on results from the phase 3 IMvigor011 trial, which used the Signatera CDx test. Patients who tested ctDNA-positive after surgery benefited from adjuvant atezolizumab (Tecentriq). In May 2026, the FDA approved Signatera CDx as a companion diagnostic to identify MIBC patients most likely to benefit from this treatment.
The updated guideline moves bladder cancer care beyond relying only on pathology results after surgery, bringing precision, biomarker-guided treatment decisions into routine practice.