Dr Martini on the Evolving Role of Intravesical Therapies in High-Risk NMIBC

"[The use of intravesical therapies] are dependent on the patient's stage and also their risk category."

Alberto Martini, MD, a urologic oncologist at University of Cincinnati Medical Center, outlined the current treatment paradigm for localized urothelial carcinoma, emphasizing the evolving role of intravesical therapies, particularly in patients with high-risk, non–muscle-invasive bladder cancer (NMIBC).

Standard management for high-risk NMIBC continues to rely on intravesical BCG as the first-line treatment. According to Martini, the initial course of BCG is typically followed by maintenance therapy in patients who do not experience recurrence. However, disease relapse or BCG failure necessitates consideration of second-line treatment options, a clinical challenge that has prompted investigation into alternative intravesical regimens and novel agents, he said.

In a recent OncLive® State of the Science Summit™ presentation focused on emerging approaches for BCG-unresponsive NMIBC, Martini discussed the use of intravesical chemotherapy with gemcitabine and docetaxel. This combination, delivered on a schedule similar to BCG, has demonstrated encouraging efficacy in the salvage setting. Although not currently considered standard of care, gemcitabine/docetaxel may offer a bladder-preserving strategy for patients who are not candidates for or wish to delay radical cystectomy.

Martini noted that several novel therapies are also under investigation in this space, including immune checkpoint inhibitors and other agents designed to enhance local immune activation or directly target urothelial carcinoma cells. Although these agents remain investigational, their incorporation into ongoing clinical trials reflects an increasing focus on expanding intravesical treatment options beyond traditional chemotherapy or BCG.

Martini concluded that taken together, these strategies highlight the importance of a nuanced approach to managing NMIBC. BCG remains foundational in high-risk disease, but alternatives such as gemcitabine/docetaxel are gaining traction, he said, adding that ongoing research into novel intravesical agents may further diversify the therapeutic armamentarium in this setting.