Intravesical Therapy

February 18, 2022

Certain types of bladder tumors are hard to remove using surgical procedures like a TURBT, particularly flat tumors (carcinoma in situ). In addition, some tumors may be likely to recur after initial resection. In these cases, special medications that destroy cancer cells may be placed directly into the bladder. This treatment is called intravesical therapy. Intravesical therapies are administered through a catheter that is placed in the bladder through the urethra. The medication is then introduced into the bladder.

The following are the principal drugs that are used as intravesical chemotherapy or immunotherapy:

What is intravesical Immunotherapy?

Bacille Calmette-Guerin or BCG

An intravesical immunotherapy that causes an immune or allergic reaction that has been shown to kill cancer cells on the lining of the bladder. BCG is often preferred for patients who have high-grade tumors or who have CIS or T1 disease. The urologist may also suggest maintenance therapy using BCG. The rationale for maintenance therapy is that the initial therapy plus intermittent therapy for 1 to 3 years may provide a decreased likelihood that the tumors will recur. The disadvantage to maintenance therapy is prolonged bladder irritation, fever, and bleeding which may force the doctor to decrease the BCG dosage or to discontinue the therapy.

What is Intravesical Chemotherapy?

Chemotherapy (chemo) drugs can be put right into the bladder through a catheter. These drugs kill actively growing cancer cells. Intravesical chemotherapy is most often used when intravesical immunotherapy with BCG doesn’t work. Giving chemo right into the bladder instead of injecting it into the bloodstream means these medicines that can kill cancer, usually do not reach and effect other parts of the body. This helps people avoid many of the side common effects that a person who receives systemic chemotherapy might experience.

Gemcitabine

An intravesical, anti-cancer drug has been shown to be effective after TURBT in reducing the number of tumor recurrences. It is usually well-tolerated and has a lower risk of chemical cystitis compared to other chemotherapy agents. Most side effects are lower urinary tract symptoms (having to urinate more frequently, more urgently, and painful urination). Sometimes this drug is given with an oral medication to change the acidity of the urine and decrease some of these side effects (called alkalization). When given directly into the bladder the likelihood of the chemotherapy getting into the blood is low, thus very few have nausea, vomiting, hair loss, and low blood counts as a side effect.

Mitomycin C

Another intravesical therapy uses Mitomycin C, an anti-cancer drug that has been shown to be effective after the TURBT in reducing the number of recurrences of bladder tumors by as much as 50%. An advantage of Mitomycin C is that it is not easily absorbed through the lining of the bladder and into the blood. It is less risky than chemotherapy given intravenously. Side effects from this drug can be pain when urinating and/or “chemical cystitis”, an irritation of the lining of the bladder which can feel like a urinary tract infection. Both these side effects are temporary and will disappear when the therapy is stopped. This drug may be delivered into the bladder immediately after TURBT.

Gemcitabine with Docetaxel

This is a combination of anti-cancer drugs that are given in the bladder for a series of installations usually in the office after TURBT. Side effects are similar to the gemcitabine alone. Usually, one drug is given and then drained out of the bladder, then the second drug is given in the same office visit.

Vicinium

The drug is indicated for patients who have had a recurrence after BCG treatments. It is a new compound that has been developed to attack a certain part of the cancer cell surface in the bladder. About half of patients have some sort of side effect, but the overwhelming majority of these are not serious. The frequency of administration is the most rigorous of all the treatments mentioned above. It starts with twice weekly treatments for 6 weeks, weekly for six weeks and then every other week after that for two years. (Please note, at this time Vicinium does not have approval from the U.S Food and Drug Administration.)

For some patients, Valrubicin may be used.  The drug is indicated for patients whose CIS bladder cancer did not respond to BCG treatment or and who cannot have surgery right away to take out the bladder.

BCAN, working with the patient advisory board for the Comparing Intravesical Therapy & Surgery as Treatment Options (CISTO) clinical trial, has developed a printable tip sheet “What You Should Know About Non-Muscle Invasive Bladder Cancer that Returns after BCG Treatment.” 

For those patients who do not respond to BCG treatment, a 2021 Bladder Cancer Think Tank session featuring co-chairs Drs. Eugene Pietzak, MD, Sumeet Bhanvadia, MD, Kelly Stratton MD, and Janet Kukreja, MD, summarized the evidence supporting other treatments. This was a  multi-disciplinary discussion on clinical trial design. They included rational combinations of novel agents, practical approaches to future comparative studies, and biomarker development to provide insight on which patients will benefit from which treatment(s). 

The above list is taken from published randomized control trials, the National Comprehensive Cancer Network guidelines and the American Urologic Association guidelines. Treatment availability varies by urologists. This is a rapidly expanding area and new drugs are expected to be added to this over the next year or two years.

Click here to read our Get the Facts | BCG (PDF), filled with advice from patients who have experienced it.  For a more in-depth look intravesical therapy to treat bladder cancer watch this Treatment Talk program by Dr. Janet Kukreja and BCAN patient advocates.  

Smartphones and tablet apps can help you better understand your bladder cancer diagnosis and treatment options. BCG Treatment—a new patient teaching app from the Roswell Park Cancer Institute ATLAS Program is now available free of charge for Apple and Google products. Use your devices to help you better understand BCG (i.e., Bacillus Calmette-Guerin) treatment. Learn about the benefits and ways to reduce or manage potential risks.

---

Information and services provided by the Bladder Cancer Advocacy Network (BCAN) are for informational purposes only. The information and services are not intended to be substitutes for professional medical advice, diagnosis or treatment. If you are ill, or suspect that you are ill, seek professional medical attention immediately! BCAN does not recommend or endorse any specific physicians, treatments, procedures or products even though they may be mentioned on this site.