Medical management of patients with refractory carcinoma in situ of the bladder

Bladder cancer is a common genitourinary malignancy and carcinoma in situ ( CIS) of the bladder exists as a potentially aggressive variant of the super ficial form of the disease. Treatment must reflect the unpredictable nature of this disease entity. In 1976. the use of intravesical Bacillus Calmette -Guerin (BCG) was described for the management of early stage bladder cance r. A subsequent report demonstrated efficacy in a cohort of patients with C IS of the bladder. Since this time. intravesical BCG has been recognised as the initial therapy for CIS of the bladder. Although a 6-week treatment wi th intravesical BCG has been established as standard therapy in patients wi th CIS- there has been no consensus as to the subsequent treatment for pati ents in the setting of failure to initial management with BCG. In addition, a number of reports have demonstrated an increased potential of adverse ef fects after repeated treatment with intravesical BCG. A variety of alternative immunological and chemotherapeutic agents have bee n developed in response to the limitations of BCG for patients with refract ory CIS of the bladder. At present, valrubicin remains the only agent that is approved by the US Food and Drug Administration for the specific indicat ion of CIS of the bladder unresponsive to intravesical BCC. Although these agents appear prom ising. the most efficacious therapy remains to be determ ined. The specific treatment protocol for refractory CIS of the bladder rem ains elusive. It is ultimately the combined decision of the clinician and p atient to determine which course of management is most beneficial.