A Phase I Intravesical PPM Therapy for NMIBC

Inclusion criteria

• Patients must meet all of the following criteria to be eligible for study entry.
• Histologically confirmed bladder carcinoma in situ (CIS) urothelial or urothelial carcinoma, with or without T1 cancer. Patients are eligible if the biopsy was done within 3 months of enrollment and a cystoscopy demonstrates no gross disease invasion into muscularis propria within 4 weeks of enrollment.
• Patient must have BCG-unresponsive non-muscle-invasive bladder cancer (NMIBC) or intolerance of treatment with BCG. Treatment of pembrolizumab is not an inclusion or

Exclusion criteria

• as intravesical taxane probably has comparable efficacy as intravenous pembrolizumab. BCG-unresponsive disease is defined as being at least one of the following:
• Persistent or recurrent CIS alone or with recurrent Ta/T1 (noninvasive papillary disease/tumor invades the subepithelial connective tissue) disease within 12 months of completion of adequate BCG therapy
• Recurrent high-grade Ta/T1 disease within 6 months of completion of adequate BCG therapy
• T1 high-grade disease at the first evaluation following an induction BCG course In this context, adequate BCG therapy is defined as at least one of the following:
• At least five of six doses of an initial induction course plus at least two of three doses of maintenance therapy
• At least five of six doses of an initial induction course plus at least two of six doses of a second induction course
• Refuse or intolerant of a radical cystectomy recommended by the treating urologist as the standard next therapy per urologic guidelines.
• Age 18 years.
• Performance status: ECOG performance status of 0, 1, or 2 (Appendix A) or Karnofsky performance status of 50 or higher (Appendix B).
• Patient with life expectancy greater than 24 months.
• No concurrent radiotherapy, chemotherapy, or other immunotherapy
• No scheduled radiotherapy, chemotherapy, other immunotherapy, or surgery before the scheduled response evaluation.
• Recovery from prior treatment side effects that might interfere with the study treatment, in the judgment of the participating urologist.
• Laboratory tests performed within 14 days of study enrollment:
• Absolute neutrophil count (AGC/ANC) 1,500/uL
• Platelets 100,000/uL \[Patients may be transfused to meet this requirement\]
• Hemoglobin 8 g/dL \[Patients may be transfused to meet this requirement\]
• Calculated glomerular filtration rate (GFR) 50 mL/min/1.73m2
• Total bilirubin 2.0 X ULN (\< 3 x ULN for patients with Gilbert's syndrome)
• AST, ALT, ALP 3.0 X ULN
• Adequate pulmonary function with no clinical signs of severe pulmonary dysfunction.
• Negative serum pregnancy test if the study participant is a female and of childbearing potential (non-childbearing is defined as greater than one year postmenopausal or surgically sterilized).
• Female participants of childbearing potential must adhere to using a medically accepted method of birth control, i.e. a tubal ligation, an approved hormonal contraceptive or an intrauterine device, prior to screening and agree to continue its use during the study and up to 3 months after finishing this study or be surgically sterilized (e.g., hysterectomy or tubal ligation). Males must agree to use barrier methods of birth control while on study.
• Provide signed informed consent and HIPAA authorization and agree to comply with all protocol-specified procedures and follow-up evaluations. Exclusion Criteria: Patients who meet any of the following criteria will be excluded from study entry.
• Existence of cancer at the upper urinary tract
• Concurrent use of other investigational agents.
• Evidence of regional and/or distant metastasis.
• NYHA (New York Heart Association) Class III or IV heart failure (Appendix C), uncontrollable supraventricular arrhythmias, any history of a ventricular arrhythmia, or other clinical signs of severe cardiac dysfunction.
• Symptomatic congestive heart failure (CHF), severe/unstable angina pectoris, or myocardial infarction within 6 months prior to study entry.
• Patient has an intractable bleeding disorder (e.g., coagulation factors deficiencies, Von Willebrand Disease).
• Patient taking medications that affect coagulation, such as aspirin (aspirin 81 mg oral once daily is allowed), Coumadin/Warfarin, heparin, low molecular weight heparin, direct thrombin inhibitors, and direct factor Xa inhibitors. Other nonsteroidal anti-inflammatory drugs (NSAIDs) are allowed as long as they are discontinued the day before therapy.
• History or evidence of uncontrollable central nervous system (CNS) disease.
• Active systemic infection requiring parenteral antibiotic therapy.
• Women who are pregnant or nursing.
• Psychiatric illness/social situations that would limit compliance with study requirements
• Other illness that in the opinion of the investigator would exclude the patient from participating in this study.
• Any other malignancy diagnosed within 3 years of trial entry with the exception of:
• Basal or squamous cell skin cancers, or
• Noninvasive cancer of the cervix, or
• Any other cancer deemed to be of low-risk for progression or patient morbidity during trial period, such as localized prostate cancer after definitive treatment and prostate-specific antigen (PSA) less than 0.2 ng/ml.
• Patients unwilling to or unable to comply with the protocol.
• Patients with impaired decision-making capacity.