New chemotherapeutic approaches in superficial bladder cancer

Key Points

Bladder cancer is the second most common genitourinary cancer in males and the fourth most common in females. There will be an estimated 71,000 new cases and 14,000 deaths from bladder cancer in 2009.¹ Approximately 70% of the time, patients present with superficial disease. Of those, 70% are Ta lesions, 20% T1, and 10% carcinoma in situ (CIS).²

Generally, low-risk tumors are treated with endoscopic resection and immediate post-resection instillation of intravesical chemotherapy. There is strong evidence to support the use of intravesical chemotherapy immediately postoperatively. However, many low-grade superficial tumors that are treated with complete resection alone will never recur. In addition, some believe that it is more cost effective to perform in-office treatment of small, low-grade, visually suspected superficial recurrent lesions than to use postoperative intravesical chemotherapy. However, the use of immediate postoperative intravesical chemotherapy has been shown to decrease recurrence rates by as much as 50% at 2 years and >15% at 5 years.⁴

An initial complete resection is desirable, as recurrence rates are never as good if any residual tumor remains in the bladder. Mitomycin C (MMC [Mutamycin]) and epirubicin (Ellence) are the two most common agents recommended for immediate post-resection instillation; however, if there is concern that the bladder was perforated during the resection, instillation should be omitted.⁵

Patients with intermediate- and high-risk tumors require additional intravesical therapy, as these groups carry higher risks of recurrence and progression. When a maintenance regimen is given, bacillus Calmette-Guérin (BCG [TheraCys, TICE BCG]) is the only intravesical agent that has been shown to decrease progression rates.^5-7 In the United States, BCG is considered the treatment of choice for high-risk superficial bladder tumors, including CIS, yet some patients either cannot tolerate BCG due to side effects or have BCG-refractory superficial bladder cancer.