Key Points
General
➤ ➤ Non-muscle invasive bladder cancer (NMIBC – sometimes referred to as
"superficial" bladder cancer) is the most common presentation of urothelial
cancer.
Bacillus Calme e-Guérin (BCG)
➤ ➤ Treatment of NMIBC depends on clinical and pathological risk stratification.
The mainstay of treatment is transurethral resection followed by intravesical
chemotherapy or immunotherapy with BCG, a live attenuated strain of
Mycobacterium bovis.
• BCG activates the immune system to recognize and destroy malignant cells.
➤ ➤ Intravesical BCG reduces the risk of progression and recurrence of NMIBC
after transurethral resection (TUR) compared to chemotherapy and is hence
preferred primary choice for all high risk and intermediate risk tumors.
Immuno-Oncology
➤ ➤ The approval of immune checkpoint blockade for patients with platinum-
resistant or -ineligible metastatic bladder cancer supports expanded use for
both advanced and, potentially, localized disease.
• Novel treatment strategies — such as those involving immune checkpoint
blockade, cytokines, monoclonocal antibodies, T-cell therapies, oncolytic
viruses and vaccines — rely on agents with immunomodulatory mechanisms.
These treatments have allowed a subset of patients to benefit from durable
response rates, often with a more tolerable adverse event profile than traditional
therapies.
• Atezolizumab, durvalumab, avelumab, pembrolizumab and nivolumab are
FDA-approved and recommended in locally advanced or metastatic urothelial
carcinoma that has previously been treated with platinum-based chemotherapy,
or has relapsed within 12 months of perioperative platinum-based
chemotherapy.
• Pembrolizumab demonstrated significant improvement in overall survival over
chemotherapy. It is the first and only therapy to show level A evidence at this
time.
• There is no reason to select one agent over the others, aside from practical
considerations of dosing and convenience.
