Intravesical and systemic chemotherapy in the management of superficial bladder cancer

M. S. Soloway

Research output: Contribution to journalReview article

20 Scopus citations

Abstract

Urologists treating patients with superficial bladder cancer have several decisions to make regarding additional therapy. First of all, the physician must categorize his patient with respect to the stage of tumor and the multiplicity of lesions. This may require mucosal biopsies in order to make an accurate estimate as to whether the patient has unifocal or multifocal disease. Based upon the above parameters, he must decide which patients should receive subsequent therapy and when to initiate treatment. Should he decide to begin intravesical prophylaxis, he must select the appropriate drug, dose, treatment schedule, and duration of treatment. For patients with carcinoma in situ or who have had multiple prior transurethral resections, the question is not whether to treat but which drug should be given. It is my personal preference to resect all tumor when possible and initiate prophylactic intravesical chemotherapy with thiotepa. I follow this approach even with an individual's first tumor(s). Although some of the other intravesical agents may prove to be more effective, the difference, if any, is small, and thiotepa is substantially less expensive that mitomycin C or Adriamycin. The primary risk with bladder cancer is myelosuppression and this must be monitored rigorously. Patients who have subsequent tumor despite thiotepa prophylaxis are still candidates for intravesical chemotherapy if the disease is superficial. The urologist must choose among three drugs: mitomycin C, Adriamycin, and bacillus Calmette-Guerin. The advantages of mitomycin are its documented effectiveness, relative lack of side effects, and established dose. The major disadvantage is its cost. If 'recurrences' are extensive, simple biopsy and initiation of a treatment schedule is appropriate. If they are easily resected, I use monthly prophylaxis. Adriamycin is also an active agent although it causes a high incidence of local irritative effects such as cystitis. It is also more expensive than thiotepa. Neither of these two agents causes myelosuppression. Bacille Calmette Guerin also appears to be effective; however, the appropriate strain, dose, and need for intradermal use have yet to be established. The role of oral agents such as pyridoxine, vitamin A analogues, or methotrexate has not been clarified as of this writing.

Original languageEnglish (US)
Pages (from-to)623-635
Number of pages13
JournalUrologic Clinics of North America
Volume11
Issue number4
StatePublished - Dec 1 1984

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ASJC Scopus subject areas

  • Urology

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