Bladder Cancer (Urothelial Cancer)

Regimen Options

Last Updated: 01/30/2026 See Details

	Evolent Pathways	Febrile Neutropenic Risk	Emetogenic Risk	References
POST-OP LOW/MOD RISK - NON-INVASIVE
	Any intra-vesicle	Not Applicable	Not applicable	NCCN Guidelines® for Bladder Cancer V.1.2024.
BCG-UNRESPONSIVE, HIGH RISK, CYSTECTOMY INELIGIBLE OR ELECTED TO NOT UNDERGO CYSTECTOMY NMIBC
	gemcitabine and docetaxel (intravesical)	Low	Minimal	NCCN Guidelines® for Bladder Cancer V.3.2025. Milbar N et. al. Bladder Cancer. 2017 Oct 27;3(4):293–303.
STAGE III
Neoadjuvant	DD-MVAC (dose-dense methotrexate, vinblastine, doxorubicin, and cisplatin)	High	High	NCCN Guidelines® for Bladder Cancer V.1.2024. Sternberg CN, et al. Eur J Cancer. 2006;42(1):50-4. Sternberg CN, et al. J Clin Oncol. 2001;19(10):2638-46.
	cisplatin and gemcitabine	Low	High	NCCN Guidelines® for Bladder Cancer V.1.2024. von der Maase H, et al. J Clin Oncol. 2005;23(21):4602-8. Dogliotti L, et al. Eur Urol. 2007;52(1):134-41.
Adjuvant	DD-MVAC (dose-dense methotrexate, vinblastine, doxorubicin, and cisplatin)	High	High	NCCN Guidelines® for Bladder Cancer V.1.2024. Sternberg CN, et al. Eur J Cancer. 2006;42(1):50-4. Sternberg CN, et al. J Clin Oncol. 2001;19(10):2638-46.
	cisplatin and gemcitabine post-surgery only, not with radiation	Low	High	NCCN Guidelines® for Bladder Cancer V.1.2024. von der Maase H, et al. J Clin Oncol. 2005;23(21):4602-8. Dogliotti L, et al. Eur Urol. 2007;52(1):134-41.
PERIOPERATIVE
	durvalumab, gemcitabine and cisplatin as neoadjuvant treatment, followed by single agent durvalumab as adjuvant treatment following radical cystectomy	Intermediate	High	NCCN Guidelines® for Bladder Cancer V.1.2025. Powles, T et. al. N Engl J Med 2024;391:1773-1786
ADVANCED/METASTATIC
Initial Therapy	cisplatin and gemcitabine	Low	High	NCCN Guidelines® for Bladder Cancer V.1.2024. von der Maase H, et al. J Clin Oncol. 2005;23(21):4602-8. Dogliotti L, et al. Eur Urol. 2007;52(1):134-41.
	carboplatin and gemcitabine	Low	Moderate	NCCN Guidelines® for Bladder Cancer V.1.2024. Hudson E, et al. Eur J Cancer Care (Engl). 2010;19(3):324-8. Dogliotti L, et al. Eur Urol. 2007;52(1):134-41.
	nivolumab, gemcitabine and cisplatin	Low	High	NCCN Guidelines® for Bladder Cancer V.1.2024. van der Heijden MS et al. N Engl J Med 2023; 389:1778-1789
Initial Therapy (for patients not eligible for any platinum-containing chemotherapy)	gemcitabine	Low	Low	NCCN Guidelines® for Bladder Cancer V.1.2024. Castagneto B et al. Oncology . 2004;67(1):27-32.
	pembrolizumab	Low	Low	NCCN Guidelines® for Bladder Cancer V.1.2024. Balar AV, et al. J Clin Oncol. 2017 35:6_suppl, 284-284. Bellmunt J, et al. N Engl J Med. 2017 Mar 16;376(11):1015-1026. Wang et al. BMC Urol. 2019; 19: 125.
Maintenance	avelumab if no progression following first-line platinum-containing chemotherapy	Low	Moderate	NCCN Guidelines® for Bladder Cancer V.1.2024. Powles T et al. N Engl J Med 2020; 383:1218-123
Subsequent Therapy	gemcitabine	Low	Low	NCCN Guidelines® for Bladder Cancer V.1.2024. Castagneto B, et al. Oncology. 2004;67(1):27-32. Lorusso V, et al. Eur J Cancer. 1998 Jul;34(8):1208-12.
	pembrolizumab failed prior platinum based chemotherapy	Low	Low	NCCN Guidelines® for Bladder Cancer V.1.2024. Balar AV, et al. J Clin Oncol. 2017 35:6_suppl, 284-284. Bellmunt J, et al. N Engl J Med. 2017 Mar 16;376(11):1015-1026. Wang et al. BMC Urol. 2019; 19: 125.
	gemcitabine and cisplatin	Low	High	NCCN Guidelines® for Bladder Cancer V.1.2024.
	gemcitabine and carboplatin	Low	High	NCCN Guidelines® for Bladder Cancer V.1.2024.
	paclitaxel	Low	Low	NCCN Guidelines® for Bladder Cancer V.1.2024.
	docetaxel	Low	Low	NCCN Guidelines® for Bladder Cancer V.1.2024.
	Best Supportive Care or Clinical Trial	Not Applicable	Not applicable	NCCN Guidelines® for Supportive Care.

POST-OP LOW/MOD RISK - NON-INVASIVE

Evolent Pathways

Any intra-vesicle

Febrile Neutropenic Risk

Emetogenic Risk

References

BCG-UNRESPONSIVE, HIGH RISK, CYSTECTOMY INELIGIBLE OR ELECTED TO NOT UNDERGO CYSTECTOMY NMIBC

Evolent Pathways

gemcitabine and docetaxel (intravesical)

Febrile Neutropenic Risk

low

Emetogenic Risk

minimal

References

STAGE III

Neoadjuvant

Evolent Pathways

DD-MVAC (dose-dense methotrexate, vinblastine, doxorubicin, and cisplatin)

Febrile Neutropenic Risk

high

Emetogenic Risk

high

References

Evolent Pathways

cisplatin and gemcitabine

Febrile Neutropenic Risk

low

Emetogenic Risk

high

References

Adjuvant

Evolent Pathways

DD-MVAC (dose-dense methotrexate, vinblastine, doxorubicin, and cisplatin)

Febrile Neutropenic Risk

high

Emetogenic Risk

high

References

Evolent Pathways

cisplatin and gemcitabine *post-surgery only, not with radiation*

Febrile Neutropenic Risk

low

Emetogenic Risk

high

References

PERIOPERATIVE

Evolent Pathways

durvalumab, gemcitabine and cisplatin as neoadjuvant treatment, followed by single agent durvalumab as adjuvant treatment following radical cystectomy

Febrile Neutropenic Risk

intermediate

Emetogenic Risk

high

References

ADVANCED/METASTATIC

Initial Therapy

Evolent Pathways

cisplatin and gemcitabine

Febrile Neutropenic Risk

low

Emetogenic Risk

high

References

Evolent Pathways

carboplatin and gemcitabine

Febrile Neutropenic Risk

low

Emetogenic Risk

moderate

References

Evolent Pathways

nivolumab, gemcitabine and cisplatin

Febrile Neutropenic Risk

low

Emetogenic Risk

high

References

Initial Therapy (for patients not eligible for any platinum-containing chemotherapy)

Evolent Pathways

gemcitabine

Febrile Neutropenic Risk

low

Emetogenic Risk

low

References

Evolent Pathways

pembrolizumab

Febrile Neutropenic Risk

low

Emetogenic Risk

low

References

Maintenance

Evolent Pathways

avelumab *if no progression following first-line platinum-containing chemotherapy*

Febrile Neutropenic Risk

low

Emetogenic Risk

moderate

References

Subsequent Therapy

Evolent Pathways

gemcitabine

Febrile Neutropenic Risk

low

Emetogenic Risk

low

References

Evolent Pathways

pembrolizumab *failed prior platinum based chemotherapy*

Febrile Neutropenic Risk

low

Emetogenic Risk

low

References

Evolent Pathways

gemcitabine and cisplatin

Febrile Neutropenic Risk

low

Emetogenic Risk

high

References

Evolent Pathways

gemcitabine and carboplatin

Febrile Neutropenic Risk

low

Emetogenic Risk

high

References

Evolent Pathways

paclitaxel

Febrile Neutropenic Risk

low

Emetogenic Risk

low

References

Evolent Pathways

docetaxel

Febrile Neutropenic Risk

low

Emetogenic Risk

low

References

Evolent Pathways

Best Supportive Care or Clinical Trial

Febrile Neutropenic Risk

Emetogenic Risk

References

	Regimen	Alternative
LOW VALUE REGIMENS (NON-PATHWAY) WITH SUPERIOR ALTERNATIVES
Neoadjuvant Therapy	capecitabine	Alternative: gemcitabine + cisplatin
Subsequent Therapy	DD-MVAC with growth factor support	Alternative: gemcitabine + cisplatin

LOW VALUE REGIMENS (NON-PATHWAY) WITH SUPERIOR ALTERNATIVES

Neoadjuvant Therapy

Regimen

** capecitabine **

Subsequent Therapy

Regimen

** DD-MVAC with growth factor support **

Pathways and Low-Value Regimens

Bladder Cancer (Urothelial Cancer)