Study aid only. Verify against current guidelines, primary literature, staging manuals, and prescribing information before clinical use.

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Non-Muscle-Invasive Bladder Cancer (NMIBC): Treatment

First-line Second-line SECOND-LINE Non–muscle-invasive bladder cancer Ta · T1 · CIS Low risk Intermediate risk High risk BCG-unresponsive CIS After TURBT Single peri-op intravesical chemo Adjuvant Intravesical chemo or BCG induction Standard BCG induction + maintenance ≥1 year Bladder-sparing Pembrolizumab KEYNOTE-057 ↗ Gene therapy Nadofaragene firadenovec intravesical Definitive Radical cystectomy preferred if fit

Non-Muscle-Invasive Bladder Cancer (NMIBC): overview

This algorithm covers non-muscle-invasive bladder cancer (Ta, T1 and CIS) and assigns intravesical therapy by risk group, with a separate branch for BCG-unresponsive disease.

After TURBT, low-risk disease receives a single perioperative instillation of intravesical chemotherapy. Intermediate-risk disease is treated with adjuvant intravesical chemotherapy or BCG induction. High-risk disease requires BCG induction plus maintenance for at least 1 year. For BCG-unresponsive CIS, radical cystectomy remains the standard and preferred definitive option for fit patients. Bladder-sparing alternatives include pembrolizumab, supported by KEYNOTE-057, which produced a 41% complete response rate in patients who could not or would not undergo cystectomy, with roughly half of responders maintaining response for 12 months or longer, and intravesical gene therapy with nadofaragene firadenovec. Throughout, BCG induction plus maintenance is the backbone for high-risk disease, and cystectomy is the reference standard once BCG fails in a fit patient.

Trials behind this algorithm

Background reading: Bladder Cancer board review notes.

Non-Muscle-Invasive Bladder Cancer (NMIBC): the algorithm in words

By risk group → intravesical therapy; BCG-unresponsive options. Starting point: Non–muscle-invasive bladder cancer Ta · T1 · CIS. Full background: Bladder Cancer notes.

Simplified board-prep scaffold; verify against current guidelines and primary literature. High-risk NMIBC needs BCG induction plus maintenance; cystectomy remains standard for fit BCG-unresponsive patients.