Intravesical pharmacotherapy for non-muscle-invasive bladder cancer: a critical analysis of currently available drugs, treatment schedules, and long-term results

OBJECTIVES: Review adjuvant intravesical pharmacotherapy for non-muscle-invasive bladder cancer (NMIBC), emphasising treatment schedules and long-term results. METHODS: Search of published literature on conventional treatment of NMIBC, emerging drugs, and device-assisted therapies. RESULTS: In low-risk NMIBC patients an immediate instillation with chemotherapy is sufficient. For patients with intermediate- or high-risk tumours, additional adjuvant instillations are needed. For intermediate-risk patients chemotherapeutic instillations, usually with mitomycin C or epirubicin, are safe and effective in reducing the risk of recurrence in the short term, but efficacy is only marginal in the long term. Newer drugs have promising results, but long term follow-up is limited or lacking. In these patients bacillus Calmette-Guérin (BCG) does not seem to be more effective, only more toxic. In high-risk NMIBC, or patients in whom chemotherapy fails, BCG is the best choice with lower rates of recurrence and progression. For BCG failures cystectomy is therapy of choice, although the combination of BCG and interferon-alpha can be considered, just as device-assisted therapies such as thermochemotherapy and electromotive drug administration. CONCLUSIONS: Risk-adapted first-line adjuvant therapy for NMIBC after TURBT is well established but has its limitations because recurrences are still numerous. Some new drugs and second-line therapies are promising, but efficacy should be confirmed.