(UroToday.com) Neoadjuvant chemotherapy (NAC) and radical cystectomy (RC) are standard of care for patients with muscle-invasive bladder cancer (MIBC). Despite level 1 evidence, and many guideline recommendations, supporting this approach, it is relatively underutilized in part due to the high patient burden from systemic toxicity and postoperative complications. Due to comorbidity or the toxicity of treatment, many patients are either ineligible or unwilling to receive this treatment approach. Further, there are concerns regarding delaying surgery, potential toxicity, and the inability to predict response and therefore know who will benefit. As a result, up to 60% of patients with MIBC may not receive definitive therapy for MIBC. However, an ability to identify patients who are more likely to respond to NAC would be helpful.