NMI bladder cancer: which adjuvant intravesical therapy is best?

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  • Compared with transurethral resection of the bladder tumor (TURBT) alone, intravesical bacillus Calmette-Guérin (BCG), mitomycin C (MMC), doxorubicin, and epirubicin were associated with reduced recurrence risk in non-muscle-invasive bladder cancer (NMIBC).  

Why this matters

  • Evidence suggests underuse of adjuvant intravesical therapy, which may be influenced by uncertainty regarding optimal treatment strategies.

Key results

  • Adjuvant BCG was associated with decreased recurrence (relative risk [RR], 0.56; I2=0%) and progression (RR, 0.39; I2=40%) vs TURBT alone. 
  • 1 trial found a nonstatistically significant trend toward decreased mortality with BCG induction therapy (RR, 0.62). 
  • MMC was associated with decreased recurrence (RR, 0.68; I2=74%). 
  • MMC was effective as maintenance (RR, 0.71; I2=6.8%) or single instillation therapy (RR, 0.45; I2=79%). 
  • Doxorubicin, epirubicin, interferon-alpha, and interferon-gamma were associated with decreased recurrence (pooled RRs, 0.63-0.80). 
  • Interferon-alpha was associated with decreased risk for progression (RR, 0.33; I2=0%). Thiotepa was associated with a nonstatistically significant decreased risk for recurrence (RR, 0.78; I2=69%). 
  • Recurrence risk was lower with BCG vs doxorubicin, epirubicin, interferon-alpha-2a, BCG plus interferon alpha-2b and thiotepa, but not MMC.

Study design

  • Meta-analysis of 39 studies published on multiple electronic databases. 
  • Funding: Agency for Healthcare Research and Quality.


  • Heterogeneity between trials. 
  • Most trials had methodological limitations.