TO THE EDITOR: We write about the Grand Rounds case discussion by Sonpavde et al in a recent issue of Journal of Clinical Oncology. The discussion illustrates the twin challenges presented by locally advanced urothelial bladder cancer. The first challenge, which was covered well in the detailed review, is the risk of distant metastases. This risk is mitigated by a 5% survival gain with neoadjuvant chemotherapy and a disease-free survival gain with adjuvant chemotherapy. What is missing from the discussion is the second oncologic challenge of pelvic recurrence. In the presented patient case, the eventual pT3N1 stage gave the patient a 15% to 30% risk of pelvic recurrence either in isolation or, more likely, together with distant relapse. This pelvic failure rate has been demonstrated in multi-institutional case series, individual institutional series, and the two large randomized trials of neoadjuvant chemotherapy, which all demonstrated that chemotherapy unfortunately does not reduce the pelvic recurrence rate. This pelvic failure is an absolute ceiling on potential curability and also can be a source of significant clinical morbidity. Bladder cancer remains the one cancer for which optimization of locoregional control with multimodality therapy has not been studied rigorously. That is now set to change with the currently accruing NRG GU001 trial, which is a phase II randomized study of postoperative adjuvant radiotherapy in this setting. If all other solid tumors can be taken as an example, it is likely that bladder cancer too will benefit from the best of surgery, adjuvant radiotherapy, and systemic treatment. It is by offering patients the possibility of enrollment into this and other trials that we will improve the outlook for this disease. To finish by returning to the presented patient case: It so happens that, in the interest of safety, the NRG trial currently excludes patients with a neo bladder, so systemic treatment is the sole active, treatment option. If the patient did not have a neoadjuvant bladder, he would have been eligible for the radiation trial even if he received systemic adjuvant treatment postoperatively.