Chemotherapy for advanced bladder cancer.

For the past 10 years, chemotherapy for advanced urothelial carcinoma has centered on cisplatin-based combination regimens such as methotrexate, vinblastine, doxorubicin and cisplatin (MVAC). Although such regimens have provided modest improvements in response rates, time to progression and survival, this has been achieved with moderate to severe toxicity. The median survival of patients with advanced disease remains at 12 to 13 months, and attempts to increase the dose intensity of existing regimens have been unsuccessful. Increasingly, attention has turned to the identification of new active agents, and a number have been recently identified, including paclitaxel, gemcitabine, ifosfamide, trimetrexate, piritrexim, and gallium nitrate. These agents will form the basis of new combination regimens that will attempt to improve on the advances in response and survival achieved with combination chemotherapy during the past decade.