# Non-muscle-invasive bladder cancer

Source: https://onco.cc/cancers/non-muscle-invasive-bladder-cancer/  
OnCo record `non-muscle-invasive-bladder-cancer` (Cancer). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Most bladder cancers are found while still confined to the lining. They are scraped out through the urethra and, when higher risk, treated with BCG instilled into the bladder; the challenge is the frequent recurrences and the patients whose tumours stop responding to BCG.

## Summary

Non-muscle-invasive bladder cancer includes papillary tumours confined to the mucosa (Ta) or lamina propria (T1) and flat carcinoma in situ. It is diagnosed by cystoscopy and removed by transurethral resection, with a single immediate dose of intravesical chemotherapy for low-risk tumours. Intermediate- and high-risk disease receives induction and maintenance intravesical BCG, the oldest cancer immunotherapy in use, which halves recurrence and reduces progression. Tumours that recur despite adequate BCG are called BCG-unresponsive; radical cystectomy is the standard, and bladder-sparing alternatives have arrived: pembrolizumab (KEYNOTE-057), nadofaragene firadenovec, nogapendekin alfa inbakicept with BCG, the gemcitabine-releasing device TAR-200 and the oncolytic virus cretostimogene. Worldwide BCG shortages have pushed dose-reduction and chemotherapy substitutes into practice. Blue-light cystoscopy improves detection of flat lesions.

## Fields

- Kind: Cancer
- Last checked: 2026-09-17
- Also known as: NMIBC; Superficial bladder cancer; Ta, T1 and carcinoma in situ of the bladder
- Tags: subtype-page
- Group: genitourinary
- Burden: About three quarters of new bladder cancers; rarely fatal at this stage but it recurs in half of patients and progresses to muscle invasion in a fifth of the high-risk group, so years of cystoscopic surveillance make it one of the most expensive cancers to manage.
- Subtypes: Low-grade Ta papillary tumours (low risk); High-grade Ta and T1 tumours (high risk); Carcinoma in situ; BCG-unresponsive disease; Upper tract urothelial carcinoma of the renal pelvis and ureter (related)
- Biomarkers: Grade and stage (EAU and AUA risk groups); Carcinoma in situ and lymphovascular invasion; FGFR3 mutations (common in low-grade disease); Urinary biomarkers and cytology for surveillance; Molecular subtypes under study

## Standard of care

- Diagnosis and resection: Cystoscopy, transurethral resection with muscle in the specimen, blue-light or enhanced imaging for carcinoma in situ; re-resection of T1 tumours. ([Bladder & urothelial cancer](https://onco.cc/cancers/urothelial/))
- Low risk: Single immediate instillation of mitomycin or gemcitabine after resection; surveillance cystoscopy. ([Mitomycin C](https://onco.cc/drugs/mitomycin/), [Gemcitabine](https://onco.cc/drugs/gemcitabine/))
- Intermediate and high risk: Induction and one to three years of maintenance BCG; intravesical chemotherapy when BCG is unavailable; early cystectomy for the highest-risk T1 disease. ([Intravesical therapy (BCG, chemotherapy, devices, gene and viral therapy)](https://onco.cc/technologies/bcg-and-intravesical-therapy/))
- BCG-unresponsive: Radical cystectomy, or bladder-sparing treatment: pembrolizumab, nadofaragene firadenovec, nogapendekin alfa inbakicept with BCG, TAR-200, cretostimogene in trials and early approvals. ([Radical cystectomy](https://onco.cc/terms/cystectomy/), [Pembrolizumab](https://onco.cc/drugs/pembrolizumab/), [Nadofaragene firadenovec](https://onco.cc/drugs/nadofaragene-firadenovec/), [Nogapendekin alfa inbakicept](https://onco.cc/drugs/nogapendekin-alfa-inbakicept/), [Gemcitabine intravesical system (TAR-200)](https://onco.cc/drugs/tar-200/), [Cretostimogene grenadenorepvec](https://onco.cc/drugs/cretostimogene/))

## State of the art

- BCG remains the standard forty years on, and shortages have shown how much depends on one biologic.
- Four bladder-sparing options for BCG-unresponsive disease have been approved or reached late trials since 2020, an unprecedented pace for this stage.
- Intravesical drug-releasing devices and gene therapies show that local delivery, not systemic drugs, is the frontier here.

## Open problems

- Recurrent BCG shortages.
- Predicting who will progress to muscle invasion.
- The burden and cost of lifelong cystoscopy.
- Comparing the new bladder-sparing options with each other and with cystectomy.

## Sources

- Wikipedia: https://en.wikipedia.org/wiki/Bladder_cancer
- Wikipedia: https://en.wikipedia.org/wiki/Bladder_cancer

## Connected records

- technologies: [Intravesical therapy (BCG, chemotherapy, devices, gene and viral therapy)](https://onco.cc/technologies/bcg-and-intravesical-therapy/)
- drugs: [Cretostimogene grenadenorepvec](https://onco.cc/drugs/cretostimogene/), [Gemcitabine](https://onco.cc/drugs/gemcitabine/), [Gemcitabine intravesical system (TAR-200)](https://onco.cc/drugs/tar-200/), [Mitomycin C](https://onco.cc/drugs/mitomycin/), [Nadofaragene firadenovec](https://onco.cc/drugs/nadofaragene-firadenovec/), [Nogapendekin alfa inbakicept](https://onco.cc/drugs/nogapendekin-alfa-inbakicept/), [Pembrolizumab](https://onco.cc/drugs/pembrolizumab/)
- cancers: [Bladder & urothelial cancer](https://onco.cc/cancers/urothelial/)
- terms: [Radical cystectomy](https://onco.cc/terms/cystectomy/)

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