Current recommendations for the management of bladder cancer. Drug therapy.

Superficial transitional cell carcinoma of the bladder is a heterogeneous group of tumours, and prediction of disease outcome in an individual patient is still impossible. In low-risk patients the initial treatment [transurethral resection (TUR)] should be followed by no or only one immediate intravesical instillation with a chemotherapeutic drug to prevent a recurrence due to tumour cell implantation during TUR. Drug efficacy has been clearly demonstrated and adverse effects are very limited. Intermediate-risk patients should receive a course of additional intravesical instillations to reduce the recurrence rate with few adverse effects. All drugs seem to be equally effective, but the long term effects remain a question. In high-risk patients intravesical immunotherapy (BCG) should be given. Although toxicity is more pronounced, it is usually mild and adverse effects disappear after cessation of therapy. BCG (maintenance) therapy seems to be able to improve progression and ultimately tumour-related survival. It is important to know the advantages and disadvantages (adverse effects) of these treatment modalities to be able to individualise treatment as much as possible. The choice is difficult because several intravesical bladder cancer trials have not reached consensus on this. For patients with non-metastasised invasive bladder tumours chemotherapy can be given before (neoadjuvant) or immediately after (adjuvant) surgery or radiotherapy. Both strategies have some advantages and disadvantages. For both, however, efficacy still needs to be proven, and results of ongoing trials are needed. For metastasised or recurrent urothelial cell carcinoma MVAC (methotrexate, vinblastine, doxorubicin and cisplatin) chemotherapy remains the most effective treatment modality. Although initial response rates of between 40% and 70% can be achieved, most patients have a recurrence of their cancer. Moreover, toxicity of these drugs also is considerable and limiting. Leucopenia is responsible for the majority of grade III and IV toxicities and subsequent dose modifications. In case of toxic deaths, a leucopenic sepsis is usually the cause. Most other adverse effects are acceptable or can be treated.