Current strategies for first and second line intravesical therapy for nonmuscle invasive bladder cancer

Nonmuscle invasive bladder cancer is a common malignancy, usually treated by transurethral resection and adjuvant intravesical instillations of chemotherapy or immunotherapy. Appropriate adjuvant treatment can be selected based on several prognostic factors that determine risk for recurrence or progression. We discuss options for first-line and second-line adjuvant therapy for nonmuscle invasive bladder cancer.

Mitomycin-C and epirubicin are the mostly used adjuvant chemotherapeutic drugs for tumours of low and intermediate risk. Bacillus Calmette-Guérin remains first-choice therapy in high-risk nonmuscle invasive bladder cancer. Gemcitabine and apaziquone are especially promising for treatment of intermediate risk nonmuscle invasive bladder cancer but require further study. Device-assisted therapies, such as thermochemotherapy and electromotive drug administration, have yielded good results in high-risk nonmuscle invasive bladder cancer and could be considered second-line therapy in this setting.

Primary problems in nonmuscle invasive bladder cancer are its tendency to recur and its elusiveness (especially high-risk nonmuscle invasive bladder cancer) of progression to muscle invasive disease. First-line adjuvant therapies are well established but suboptimal. Some second-line therapies are promising but should be used cautiously, because in some patients the best option is not always the conservative one.