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Editorial Comment from Dr Ide to Substratification of patients with highest‐risk non‐muscle invasive bladder cancer helps to identify the candidates for immediate radical cystectomy: A two‐center study

for patients with high-grade T1 bladder cancer. However, immediate RC in all patients will result in overtreatment. Recently, a variation in the biological aggressiveness of highgrade T1 bladder cancer has been identified. In the 2017 European Association of Urology guideline, high-grade T1 cancer was classified as high risk or highest risk. However, even for the highest-risk cancers, the probability of muscle invasion is up to 40% at 5 years in the 2021 European Association of Urology non-muscle invasive bladder cancer scoring model. In clinical practice, establishing a method for selection of patients with high-grade T1 bladder cancer who are suitable for immediate RC is an urgent unmet need. In this study, Tao et al. retrospectively evaluated 262 patients with high-grade primary T1 bladder cancer and found that multiple tumors, concomitant carcinoma in situ, and lymphovascular invasion were significantly associated with recurrence and progression of cancer using multivariable Cox analysis. The authors also predict that patients with two or three risk factors would have poor progression-free survival and strongly recommend immediate RC for these patients. They suggest that bladder-sparing treatment may be worthwhile in patients with up to one risk factor if they are unwilling to undergo RC. In the real-world setting, even though it is estimated that more than 60% of patients with high-grade T1 bladder cancer have additional risk factors for progression, fewer than 10% of these patients undergo immediate RC. In addition to reluctance on the part of patients, many urologists may prefer to perform bladder-sparing treatment, such as intravesical bacillus Calmette–Guerin (BCG) immunotherapy, until progression. However, predictors of the efficacy of intravesical BCG treatment have not yet been established. Moreover, the opportunity for a complete cure may be missed if RC is delayed in preference to intravesical therapy. This study demonstrated that substratification of high-grade T1 bladder cancer based on the number of risk factors enabled more accurate categorization of patients and better surgical decision-making. Strategies that include assessment of molecular and clinicopathological factors to identify patients at risk of failure of bladder-sparing treatments are also needed in the future.