Methods for treating lower urothelial cancer

Abstract

The present invention provides methods, devices, and kits for treating urothelial carcinoma of the lower urinary tract using an antimetabolite (e.g., gemcitabine). In some embodiments, these methods, devices, and kits relate to treating urothelial carcinoma of the lower urinary tract using an antimetabolite (e.g., gemcitabine) and an immunomodulatory agent. Local administration of an antimetabolite, such as gemcitabine, to the bladder can have multiple biological effects, such as modulating immune responses in the tumor microenvironment, inducing systemic immunity and antigen presentation, and inducing cytotoxicity.

Description

Technical Field

[0001] Cross - Reference to Related Applications This application claims the benefit and priority of U.S. Provisional Application No. 62 / 333,151, filed on May 6, 2016, and U.S. Provisional Application No. 62 / 443,614, filed on January 6, 2017. The entire contents of each of these applications are hereby incorporated by reference in their entirety into this specification.

Background Art

[0002] Background of the Invention Bladder cancer is a significant medical problem, and currently available treatment options are not satisfactory for many reasons. Generally, bladder cancer is classified as muscle - invasive bladder cancer (MIBC) or non - muscle - invasive bladder cancer (NMIBC). The pathological classification and staging of bladder cancer are as follows: pTa (urothelial involvement); pTis (high - risk urothelial carcinoma in situ); pT1 (lamina propria invasion); pT2 (muscle invasion); pT3 (perivesical fat invasion); and pT4 (invasion of pelvic organs). Bladder cancer can also be classified by grade as grade 1 / 3 (well - differentiated); grade 2 / 3 (moderately differentiated); grade 3 / 3 (poorly differentiated). Further, bladder cancer can be classified by stage as stage 0 - IV. Most bladder cancers are transitional cell carcinomas of epithelial origin and are classified as non - muscle - invasive cancers (NMIBC) confined to the inner layer of the bladder. At the time of initial presentation, most bladder cancers are superficial NMIBC, which includes diseases at stages pTa, pTis, and pT1. MIBC includes stages pT2, pT3, and pT4.

[0003] A typical clinical protocol for early-stage NMIBC is visualization by cystoscopy followed by surgical removal of the tumor(s), known as transurethral resection (TUR). However, the recurrence rate after surgery is high, and the cancer can progress to muscle-invasive disease. Thus, surgery is often combined with adjuvant intravesicular (intra-bladder) instillation of chemotherapeutic or immunotherapeutic agents (direct delivery of chemotherapeutic agents into the bladder via a urinary catheter) to help prevent or delay the incidence and severity of recurrence. Bacillus Calmette-Guérin (BCG) is such an immunotherapeutic agent and is typically instilled into the bladder after surgery. However, many patients do not respond to BCG, and BCG treatment can also induce various adverse effects, leading to treatment interruption. Chemotherapeutic agents are usually reserved for patients in whom BCG treatment has failed. Chemotherapy is typically applied intravesically to concentrate the chemotherapeutic agent at the tumor site, eliminating any residual tumor after resection while avoiding systemic exposure to the drug.

[0004] One such chemotherapeutic agent used in clinical trials to treat bladder cancer is gemcitabine. Gemcitabine (2’,2’-difluorodeoxycytidine) is a pyrimidine analog with activity against metastatic bladder cancer. Gemcitabine has also been used in clinical trials to treat superficial bladder cancer and NMIBC by instillation into the bladder on various weekly schedules. Gemcitabine is typically instilled once or twice a week over several weeks, over a period of 1 - 2 hours, typically at a dose in the range of 500 - 2000 mg in up to 100 mL of saline.

[0005] Such liquid formulations are known to have limited therapeutic benefits since they are excreted from the bladder after a short dwell time of 1-2 hours. Further, high concentrations (40 mg / mL) and high doses (up to 2 grams per infusion) have been used in attempts to achieve therapeutic tissue levels in an attempt to overcome the limitation of the dwell time. However, intravesical (into the bladder) delivery of high doses of gemcitabine can result in significant systemic absorption, can cause gastrointestinal, bladder and bone marrow toxicities, and in addition to local tolerability issues, further limits clinical utility.

[0006] Therefore, there is still a need for an improved method for treating urothelial carcinoma of the lower tract.

[0007] The published applications US2012 / 0203203, US2013 / 0158675, US2015 / 0360012, US20150165177, US2015 / 0165178, US20160199544, WO2014 / 145638, WO2015200752, WO2011 / 031855 are hereby incorporated by reference in their entirety. All other references disclosed herein are hereby incorporated by reference in their entirety.

Prior Art Documents

Patent Documents

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Patent Document 1

Patent Document 2

Patent Document 3

Patent Document 4

Patent Document 5

Patent Document 6

Patent Document 7

Patent Document 8

Patent Document 9

Summary of the Invention

Means for Solving the Problems

[0009] Brief Summary of the Invention Local administration of antimetabolites such as gemcitabine to the bladder results in multiple biological effects such as modulating the immune response in the tumor microenvironment, inducing systemic immunity and antigen presentation, and inducing cytotoxicity. Accordingly, the present application discloses a method for treating urothelial carcinoma of the lower urinary tract, the method comprising the step of locally administering an effective amount of an antimetabolite to an individual into the bladder.

[0010] In some embodiments, the method is a method of enhancing the immune response against urothelial carcinoma of the lower urinary tract of an individual, the method comprising the step of administering to the individual an effective amount of an antimetabolite, wherein the antimetabolite is delivered locally to the bladder.

[0011] In some embodiments, the method is a method of reducing recurrence or progression of urothelial carcinoma of the lower urinary tract in an individual, the method comprising the step of administering to the individual an effective amount of an antimetabolite, wherein the antimetabolite is delivered locally to the bladder.

[0012] In some embodiments, the method is a method of improving the tumor microenvironment for cancer immunotherapy in an individual having urothelial carcinoma of the lower urinary tract, the method comprising the step of administering to the individual an effective amount of an antimetabolite, wherein the antimetabolite is delivered locally to the bladder.

[0013] In some embodiments, the method is a method of sensitizing an individual having urothelial carcinoma of the lower urinary tract for radiotherapy, the method comprising administering to the individual an effective amount of an antimetabolite, the antimetabolite being delivered locally to the bladder.

[0014] In some embodiments according to any of the above methods, the method is a method of treating muscle-invasive bladder cancer in an individual, the method comprising locally delivering to the bladder an effective amount of gemcitabine, the gemcitabine being delivered continuously for at least 24 hours.

[0015] In some embodiments according to any of the above methods, the method is a method of bladder preservation in an individual, the method comprising locally delivering to the bladder an effective amount of gemcitabine, the gemcitabine being delivered continuously for at least 24 hours.

[0016] In some embodiments according to any of the above methods, the method is a method of treating non-muscle-invasive bladder cancer in an individual, the method comprising locally delivering gemcitabine to the bladder, the gemcitabine being delivered continuously for at least 24 hours.

[0017] In some embodiments according to any of the above methods, the antimetabolite can be a nucleoside analog. In some of these embodiments, the antimetabolite is gemcitabine. In some embodiments according to any of the above methods, the antimetabolite is delivered continuously into the bladder over a period of at least about 24 hours. In some embodiments according to any of the above methods, the antimetabolite is delivered at a first dose at a first time of delivery and then at a second dose at a second time of delivery. In some embodiments, the first time and the second time are consecutive. Alternatively, in some embodiments, the first and second times can be separated by a drug-free period.

[0018] In some embodiments according to any of the above methods, the antimetabolite is delivered at a dosage of about 1 mg / day to about 300 mg / day. In some embodiments according to any of the above methods, the concentration of the antimetabolite in urine is about 0.1 μg / mL to about 200 μg / mL during the delivery period. In some of these embodiments according to any of the above methods, the concentration of the antimetabolite in urine is about 10 μg / mL during the delivery period. In some embodiments according to any of the above methods, the concentration of the antimetabolite in the plasma of the individual is less than about 1 μg / mL. In some embodiments according to any of the above methods, the concentration of the antimetabolite is less than about 0.1 μg / mL. In some embodiments according to any of the above methods, upon delivery of the antimetabolite, the ratio of the antimetabolite in the urine of the individual to the antimetabolite in the plasma is greater than about 500:1.

[0019] In some embodiments according to any of the above methods, the antimetabolite is delivered over at least 1 month, each antimetabolite delivery period is at least 1 day, and the interval between each antimetabolite delivery period is about 1 week or less. In some embodiments according to any of the above methods, the interval between each antimetabolite period is 14 days. In some embodiments, there is no interval between each antimetabolite delivery period.

[0020] In some embodiments, the method includes: a) a first antimetabolite delivery period in which the concentration of the antimetabolite in the urine of the individual is at least about 0.1 μg / mL; b) a drug withdrawal period; and c) a second antimetabolite delivery period in which the concentration of the antimetabolite in the urine of the individual is at least about 0.1 μg / mL over at least a portion of the drug withdrawal period. In some embodiments, the concentration of the antimetabolite in urine is higher than about 1.0 μg / mL over at least about half of the drug withdrawal period.

[0021] In some embodiments according to any of the above methods, the method further comprises administering to the individual an effective amount of a second agent. In some embodiments according to any of the above methods, the second agent is administered at the time when the antimetabolite delivery is initiated. In some embodiments, the second agent is administered before the antimetabolite is delivered. In some embodiments, the second agent is administered after the antimetabolite delivery is initiated. In still further embodiments, the second agent is administered after the antimetabolite delivery is terminated.

[0022] In some embodiments according to any of the above methods, the antimetabolite delivery period and the second agent delivery period may overlap with each other. In some embodiments, the antimetabolite delivery period and the second agent delivery period may be non-overlapping.

[0023] In some aspects according to any of the above methods, the second agent is delivered systemically. In other aspects, the second agent is delivered locally. In some embodiments, the second agent is delivered systemically at a first time of the second agent delivery period, followed by local delivery at a second time of the second agent delivery period. In some embodiments, the second agent is delivered locally at a first time of the second agent delivery period, followed by systemic delivery at a second time of the second agent delivery period. In some embodiments, the first time of the second agent delivery period and the second time of the second agent delivery period are separated by at least about one month.

[0024] In some embodiments according to any of the above methods, the antimetabolite and the second agent are delivered simultaneously. In some of these embodiments, the antimetabolite and the second agent are delivered via a single delivery device. In some embodiments according to any of the above methods, the antimetabolite and the second agent are delivered at the same release rate. In other embodiments, the antimetabolite and the second agent are delivered at different release rates.

[0025] In some embodiments, the second agent is delivered separately from the antimetabolite.

[0026] In some embodiments according to any of the above methods, the second agent is delivered systemically. In some embodiments, the second agent is delivered locally.

[0027] In some embodiments according to any of the above methods, the second agent is a chemotherapeutic agent. In some embodiments according to any of the above methods, the chemotherapeutic agent is selected from the group consisting of paclitaxel, docetaxel, carboplatin, cisplatin, and oxaliplatin. In some embodiments, the second agent is an immunomodulatory agent. In some embodiments, the immunomodulatory agent is an immune checkpoint inhibitor. In some embodiments, the immune checkpoint inhibitor is an inhibitor of an immune checkpoint protein selected from the group consisting of PD-L1, CTLA4, PD-L2, PD-1, B7-H3, B7-H4, HVEM, B and T lymphocyte attenuator (BTLA), killer inhibitory receptor (KIR), GAL9, TIM3, A2AR, LAG-3, phosphatidylserine, CD27, TNF-α, CD33, Siglec-5, Siglec-7, Siglec-9, and Siglec-11. In some embodiments, the immunomodulatory agent is an agonist of a costimulatory immune molecule. In some embodiments, the costimulatory immune molecule is selected from the group consisting of CD40, OX40, ICOS, CD28, CD137 / 4-1BB, CD27, IL-10, TGF-beta, TOR receptor, and glucocorticoid-induced TNFR-related protein GITR.

[0028] In some embodiments according to any of the above methods, the individual does not receive radiation therapy. In other embodiments, the method further includes radiation therapy.

[0029] In some embodiments according to any of the above methods, the antimetabolite is delivered in a neoadjuvant setting. In some embodiments, the antimetabolite is delivered in an adjuvant setting. In some embodiments according to any of the above methods, the antimetabolite is delivered in a preoperative treatment. In some embodiments, the antimetabolite is delivered in a perioperative treatment.

[0030] In some embodiments according to any of the above methods, the method further includes a third treatment including surgery. In some of these embodiments, delivery of the antimetabolite to the individual can be initiated at the time of surgery. In some embodiments according to any of the above methods, delivery of the antimetabolite to the individual is initiated during cystoscopy. In some embodiments according to any of the above methods, delivery of the antimetabolite to the individual is initiated during a pre-surgical cystoscopy. In some embodiments, delivery of the antimetabolite to the individual is initiated during a post-surgical cystoscopy.

[0031] In some embodiments according to any of the above methods, the antimetabolite is delivered into the bladder by an intravesical (within the bladder) device. In some of these embodiments according to any of the above methods, the intravesical (within the bladder) device includes a housing configured for intravesical (within the bladder) insertion; and a dosage form containing the antimetabolite, the housing being configured to hold the dosage form and release the antimetabolite in an amount effective for the treatment of urothelial cancer. In some embodiments according to any of the above methods, the intravesical (within the bladder) drug delivery device includes a housing that contains the antimetabolite, controllably releases it, and is elastically deformable between a retention shape configured to hold the device in the individual's bladder and a deployment shape for passage of the device through the individual's urethra. In some embodiments according to any of the above devices, the device includes a drug reservoir lumen bounded by a first wall and a second wall, the first wall being impermeable to the drug and the second wall being permeable to the drug. In some embodiments according to any of the above devices, the first wall and the second wall are adjacent to each other and together form an annular tube defining the drug reservoir lumen. In some embodiments according to any of the above devices, the second wall is in the form of a strip extending at least partially along the length of the structure of the first wall. In some embodiments, the first wall is cylindrical. In some embodiments, the second wall is disk-shaped. In some embodiments, the intravesical (within the bladder) drug delivery device includes at least two drug reservoir lumens.

[0032] In some embodiments according to any of the above methods, when a device is used to deliver an antimetabolite, the antimetabolite is released from the device by osmotic pressure. In some embodiments, the antimetabolite is released from the device by diffusion.

[0033] In some embodiments according to any of the above devices, the antimetabolite contained in the housing is in a non-liquid form. In some of these embodiments, the non-liquid form is selected from the group consisting of tablets, granules, semi-solids, powders, capsules, and combinations thereof.

[0034] In some embodiments according to any of the above methods, the methods provided herein include a method of treating urothelial carcinoma of the lower urinary tract, wherein the urothelial carcinoma is bladder cancer. In some embodiments, the bladder cancer is locally advanced bladder cancer or metastatic bladder cancer. In some embodiments, the bladder cancer is muscle-invasive bladder cancer. In some embodiments, the bladder cancer is non-muscle-invasive bladder cancer. In some embodiments according to any of the above methods, the bladder cancer is carcinoma in situ. In some embodiments, the bladder cancer is BCG (Bacillus Calmette-Guérin) - refractory cancer or papillary bladder cancer. In some embodiments, the bladder cancer is BCG-non-responsive cancer.

[0035] In some embodiments according to any of the above methods, the method includes administering to the individual an effective amount of an antimetabolite, wherein the individual is a human. In some embodiments according to any of the above methods, the individual is not suitable for systemic treatment. In some embodiments according to any of the above methods, the individual has a compromised immune system. In some embodiments according to any of the above methods, the individual has a high level of immune checkpoint protein. In some embodiments, the individual has a low level of immune checkpoint protein. In some embodiments according to any of the above methods, the individual has a high level of nucleoside transporter. In some embodiments, the individual has a lower level of nucleoside transporter.

[0036] In some embodiments according to any of the above methods, the antimetabolite is gemcitabine, and the method further includes the step of determining the gemcitabine / metabolite ratio in urine, and a ratio below the threshold indicates effective treatment.

[0037] In some embodiments, provided herein is a kit for treating urothelial carcinoma of the lower urinary tract in an individual, the kit comprising a) an antimetabolite and b) a second agent, wherein the antimetabolite is in a device for local delivery to the bladder. In some of these embodiments, the antimetabolite is gemcitabine. In some embodiments, the second agent is an immunomodulatory agent.

[0038] Also provided herein is a device for local delivery of an antimetabolite and a second agent to the bladder of an individual, the device comprising a) an antimetabolite and b) a second agent. In some embodiments, the antimetabolite is gemcitabine. In some embodiments, the second agent is an immunomodulatory agent.

[0039] In some embodiments according to any of the above devices, the intravesical (intra - bladder) drug delivery device comprises a housing that defines a reservoir; a first unit contained within the reservoir, the first unit containing an antimetabolite; and a second unit contained within the reservoir at a location separate from the first unit, the second unit containing a functional agent that facilitates in vivo release of the drug from the housing. In some embodiments, the functional agent is a penetration enhancer, a solubilizing agent for the drug, or a combination thereof, and the housing includes at least one drug release opening in fluid communication with the reservoir. In certain embodiments, for example, the following items are provided. (Item 1) A method for treating urothelial carcinoma of the lower urinary tract in an individual, comprising the step of administering to the individual an effective amount of an antimetabolite, wherein the antimetabolite is delivered locally to the bladder, and the urothelial carcinoma of the lower urinary tract is muscle-invasive bladder cancer. (Item 2) The method according to item 1, wherein the individual is not suitable for radical cystectomy. (Item 3) The method according to item 1 or 2, wherein the individual cannot tolerate systemic chemotherapy and / or chemotherapy with drugs other than the antimetabolite. (Item 4) The method according to any one of items 1 to 3, wherein the individual does not undergo radical cystectomy. (Item 5) A method for treating urothelial carcinoma of the lower urinary tract in an individual, comprising the step of administering to the individual an effective amount of an antimetabolite, wherein the antimetabolite is delivered locally to the bladder, and the urothelial carcinoma of the lower urinary tract is non-muscle-invasive bladder cancer. (Item 6) A method for treating urothelial carcinoma of the lower urinary tract in an individual, comprising the step of administering to the individual an effective amount of an antimetabolite, wherein the antimetabolite is delivered locally to the bladder, and the method further comprises the step of administering to the individual an effective amount of a second drug. (Item 7) The method according to any one of items 1 to 6, wherein the antimetabolite is a nucleoside analog. (Item 8) The method according to any one of items 1 to 7, wherein the antimetabolite is gemcitabine. (Item 9) The method according to item 8, wherein the gemcitabine is continuously delivered to the bladder of the individual over a period of 24 hours to 6 weeks. (Item 10) A method for bladder preservation in an individual, comprising the step of locally delivering an effective amount of gemcitabine to the bladder, wherein the gemcitabine is continuously delivered to the bladder of the individual over a period of 24 hours to 6 weeks, and the individual has urothelial carcinoma of the lower urinary tract. (Item 11) The method according to any one of items 8 to 10, wherein the gemcitabine is continuously delivered to the bladder of the individual over a period of 24 hours to 3 weeks. (Item 12) The method according to any one of items 8 to 11, wherein the gemcitabine is continuously delivered to the bladder of the individual over a period of 7 days. (Item 13) The method according to any one of items 8 to 11, wherein the gemcitabine is continuously delivered to the bladder of the individual over a period of 3 weeks. (Item 14) The method according to any one of items 8 to 13, comprising a first gemcitabine delivery period and a second gemcitabine delivery period. (Item 15) The method according to item 14, wherein the first and second gemcitabine delivery periods are each 7 days. (Item 16) The method according to item 14, wherein the first and second gemcitabine delivery periods are each 3 weeks. (Item 17) The method according to any one of items 14 to 16, wherein the first and second gemcitabine delivery periods are separated by a 14-day drug-free period. (Item 18) The method according to any one of items 1 to 17, wherein the antimetabolite is delivered at a first release rate at a first time of the delivery, and then followed by a second time of the delivery having a second release rate. (Item 19) The method according to any one of items 1 to 18, wherein the antimetabolite is delivered at a dose of about 1 mg / day to about 300 mg / day. (Item 20) The method according to any one of items 1 to 19, wherein the concentration of the antimetabolite in urine is about 0.1 μg / mL to about 200 μg / mL during the delivery period. (Item 21) The method according to item 20, wherein the concentration of the antimetabolite in urine is about 1 μg / mL to about 10 μg / mL during the delivery period. (Item 22) The method according to item 20, wherein the concentration of the antimetabolite in urine is about 10 μg / mL during the delivery period. (Item 23) The method according to any one of items 1 to 22, wherein the concentration of the antimetabolite in the plasma of the individual is less than about 1 μg / ml. (Item 24) The method according to any one of items 1 to 23, wherein the ratio of the antimetabolite in the urine of the individual to the antimetabolite in the plasma during the delivery of the antimetabolite is greater than about 500:1. (Item 25) a) a first antimetabolite delivery period in which the concentration of the antimetabolite in the urine of the individual is at least about 0.1 μg / mL; b) a drug-free period; and c) a second antimetabolite delivery period in which the concentration of the antimetabolite in the urine of the individual is higher than about 0.1 μg / mL The method according to any one of items 1 to 24, comprising. (Item 26) The method according to item 25, wherein the concentration of the antimetabolite in urine is higher than about 1 μg / mL for at least half of the drug-free period. (Item 27) The method according to any one of items 1 to 26, further comprising the step of administering an effective amount of a second agent to the individual. (Item 28) The method according to item 27, wherein the second agent is systemically delivered. (Item 29) The method according to item 27, wherein the second agent or the second chemotherapeutic agent is delivered locally. (Item 30) The method according to item 29, wherein the antimetabolite and the second agent are delivered via a single delivery device. (Item 31) The method according to any one of items 28 to 30, wherein the second agent is an immunomodulatory agent. (Item 32) The method according to item 31, wherein the immunomodulatory agent is an immune checkpoint inhibitor. (Item 33) The method according to item 32, wherein the immune checkpoint inhibitor is an inhibitor of an immune checkpoint protein selected from the group consisting of PD-L1, CTLA4, PD-L2, PD-1, B7-H3, B7-H4, HVEM, B and T lymphocyte attenuator (BTLA), killer inhibitory receptor (KIR), GAL9, TIM3, A2AR, LAG-3, phosphatidylserine, CD27, TNF-α, CD33, Siglec-5, Siglec-7, Siglec-9 and Siglec-11. (Item 34) The method according to item 32, wherein the immunomodulatory agent is an agonist of a costimulatory immune molecule. (Item 35) The method according to item 34, wherein the costimulatory immune molecule is selected from the group consisting of CD40, OX40, ICOS, CD28, CD137 / 4-1BB, CD27, IL-10, TGF-beta, TOR receptor and glucocorticoid-induced TNFR-related protein GITR. (Item 36) The method according to any one of items 27 to 30, wherein the second agent is a second chemotherapeutic agent. (Item 37) The method according to item 36, wherein the chemotherapeutic agent is selected from the group consisting of paclitaxel, docetaxel and oxaliplatin. (Item 38) The method according to any one of items 1 to 37, wherein the individual does not receive radiotherapy. (Item 39) The method according to any one of items 1 to 38, further comprising radiotherapy. (Item 40) The method according to any one of items 1 to 39, wherein the antimetabolite is delivered in a neoadjuvant setting. (Item 41) The method according to any one of items 1 to 39, wherein the antimetabolite is delivered in an adjuvant setting. (Item 42) The method according to any one of items 1 to 41, further comprising a third treatment including surgery, and delivery of the antimetabolite to the individual being initiated at the time of the surgery. (Item 43) The method according to any one of items 1 to 42, wherein the metabolic antagonist is delivered into the bladder by a bladder cavity delivery device. (Item 44) The method according to item 43, wherein the intravesical device contains 100 mg to 500 mg of gemcitabine. (Item 45) The method according to item 44, wherein the intravesical device contains 225 mg of gemcitabine. (Item 46) The method according to any one of items 43 to 45, wherein the intravesical device includes a housing configured for insertion into the bladder cavity; and a dosage form containing a metabolic antagonist, the housing being configured to hold the dosage form and release the metabolic antagonist in an amount effective for treating urothelial carcinoma of the lower urinary tract. (Item 47) The intravesical drug delivery device Has a housing that defines a reservoir; A first unit contained within the reservoir, the first unit containing a metabolic antagonist; and A second unit contained within the reservoir at a position separate from the first unit, the second unit containing a functional agent that promotes the in vivo release of the metabolic antagonist from the housing The method according to any one of items 43 to 46, comprising. (Item 48) The method according to any one of items 43 to 47, wherein the intravesical drug delivery device includes a housing that contains the metabolic antagonist, releases it controllably, and is elastically deformable between a retention shape configured to hold the device in the bladder of the individual and a deployment shape for passage of the device through the urethra of the individual. (Item 49) The method according to any one of items 43 to 48, wherein the device includes a drug reservoir lumen bounded by a first wall and a second wall, the first wall being impermeable to the drug, and the second wall being permeable to the metabolic antagonist. (Item 50) The method according to any one of items 43 to 49, wherein the intravesical drug delivery device includes at least two drug reservoir lumens. (Item 51) The method according to any one of items 43 to 50, wherein the metabolic antagonist is released from the device by osmotic pressure. (Item 52) The method according to any one of items 43 to 51, wherein the metabolic antagonist is released from the device by diffusion. (Item 53) The method according to any one of items 43 to 52, wherein the metabolic antagonist contained in the housing is in a non-liquid form. (Item 54) The method according to item 53, wherein the non-liquid form is selected from the group consisting of tablets, granules, powders, semi-solids, capsules and combinations thereof. (Item 55) The method according to any one of items 6 to 54, wherein the urothelial cancer of the lower urinary tract is bladder cancer. (Item 56) The method according to item 55, wherein the bladder cancer is muscle-invasive bladder cancer. (Item 57) The method according to item 55, wherein the bladder cancer is non-muscle-invasive bladder cancer. (Item 58) The method according to any one of items 1 to 4 or 6 to 55, wherein the bladder cancer is locally advanced bladder cancer or metastatic bladder cancer. (Item 59) The method according to any one of items 5 to 55, wherein the bladder cancer is intraepithelial carcinoma. (Item 60) The method according to any one of items 1 to 55, wherein the bladder cancer is BCG (Bacillus Calmette-Guérin) - refractory or BCG-resistant cancer or papillary bladder cancer. (Item 61) The method according to any one of items 1 to 60, wherein the individual is a human. (Item 62) The method according to any one of items 1 to 61, wherein the individual is unsuitable for systemic chemotherapy. (Item 63) The method according to any one of items 1 to 62, wherein the individual has a compromised immune system. (Item 64) The method according to any one of items 1 to 63, wherein the individual has a high level of immune checkpoint protein. (Item 65) The method according to any one of items 1 to 63, wherein the individual has a low level of immune checkpoint protein. (Item 66) The method according to any one of items 1 to 65, wherein the individual has a high level of nucleoside transporter. (Item 67) The method according to any one of items 1 to 65, wherein the individual has a low level of nucleoside transporter. (Item 68) The method according to any one of items 8 to 67, further comprising the step of determining the gemcitabine / metabolite ratio in urine, wherein a ratio below the threshold indicates an effective treatment. (Item 69) A kit for treating urothelial cancer of the lower urinary tract in an individual, comprising a) an antimetabolite and b) an immunomodulatory agent, wherein the antimetabolite is in a device for local delivery to the bladder. (Item 70) A kit for treating urothelial carcinoma of the lower urinary tract in an individual, comprising a) an antimetabolite and b) a second agent, wherein the antimetabolite is in a device for local delivery to the bladder, and the urothelial carcinoma of the lower urinary tract is muscle-invasive bladder cancer. (Item 71) The kit according to item 70, wherein the second agent is an immunomodulatory agent. (Item 72) The kit according to item 69 or 70, wherein the antimetabolite is gemcitabine. (Item 73) A delivery device for local delivery of an antimetabolite and a second agent to an individual's bladder, comprising a housing containing the antimetabolite and the immunomodulatory agent, wherein the housing is configured to provide local release of the antimetabolite and the second agent into the individual's bladder. (Item 74) The delivery device according to item 73, wherein the antimetabolite is gemcitabine. (Item 75) The delivery device according to item 73 or 74, wherein the second agent is an immunomodulatory agent. (Item 76) A method of enhancing an immune response against urothelial carcinoma of the lower urinary tract in an individual, comprising administering to the individual an effective amount of an antimetabolite, wherein the antimetabolite is locally delivered to the bladder.

Brief Description of the Drawings

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[0050] This application provides a novel method for treating urothelial carcinoma of the lower urinary tract (e.g., bladder cancer) via local delivery of a metabolic antagonist (e.g., gemcitabine) to the bladder. This application is based in part on the surprising finding that local delivery of gemcitabine using a particular dosing regimen results in multiple biological effects such as modulating the immune response in the tumor microenvironment, inducing systemic immunity and antigen presentation, and inducing cytotoxicity. It has further surprisingly been found that when locally delivered to the bladder using a particular dosing regimen, gemcitabine penetrates deeply into bladder tissue and persists in urine for an extended period even after delivery has ceased. Thus, local delivery of a metabolic antagonist to the bladder as described herein is useful for treating urothelial carcinoma of the lower urinary tract, particularly when used in combination with a second agent (e.g., an immunomodulatory agent).

[0051] Accordingly, the present invention, in various aspects, provides a method of treating urothelial carcinoma of the lower urinary tract in an individual, a method of enhancing an immune response against urothelial carcinoma of the lower urinary tract in an individual, a method of reducing recurrence or progression of urothelial carcinoma of the lower urinary tract in an individual, a method of improving the tumor microenvironment for cancer immunotherapy, and a method of sensitizing an individual having urothelial carcinoma of the lower urinary tract for radiotherapy, the method comprising administering to the individual an effective amount of an antimetabolite, wherein the antimetabolite is delivered locally to the bladder. In some embodiments, the method further comprises the delivery of a second agent, such as an immunomodulatory agent. In some embodiments, the individual is unsuitable for systemic administration or is immunocompromised.

[0052] In another aspect, there is provided a kit for treating urothelial carcinoma of the lower urinary tract in an individual, the kit comprising a) an antimetabolite and b) a second agent, wherein the gemcitabine antimetabolite is in a device for local delivery to the bladder. In another aspect, there is provided a device for local delivery of an antimetabolite and a second agent to the bladder, the device comprising a) an antimetabolite and b) a second agent. In some embodiments, the antimetabolite is gemcitabine. In some embodiments, the second agent is an immunomodulator. I. Methods of the Invention

[0053] In some embodiments, the present application provides a method for treating urothelial carcinoma of the lower urinary tract in an individual, the method comprising delivering to the individual an effective amount of an antimetabolite (e.g., a nucleoside analog, e.g., gemcitabine), wherein the antimetabolite (e.g., a nucleoside analog, e.g., gemcitabine) is delivered locally to the bladder. In some embodiments, the present application provides a method for enhancing an immune response against urothelial carcinoma of the lower urinary tract in an individual, the method comprising delivering to the individual an effective amount of an antimetabolite (e.g., a nucleoside analog, e.g., gemcitabine), wherein the antimetabolite (e.g., a nucleoside analog, e.g., gemcitabine) is delivered locally to the bladder. In some embodiments, the present application provides a method for reducing recurrence or progression of urothelial carcinoma of the lower urinary tract in an individual, the method comprising delivering to the individual an effective amount of an antimetabolite (e.g., a nucleoside analog, e.g., gemcitabine), wherein the antimetabolite (e.g., a nucleoside analog, e.g., gemcitabine) is delivered locally to the bladder. In some embodiments, the present application provides a method for improving the tumor microenvironment for cancer immunotherapy in an individual having urothelial carcinoma of the lower urinary tract, the method comprising delivering to the individual an effective amount of an antimetabolite (e.g., a nucleoside analog, e.g., gemcitabine), wherein the antimetabolite (e.g., a nucleoside analog, e.g., gemcitabine) is delivered locally to the bladder. In some embodiments, the urothelial carcinoma of the lower urinary tract is muscle-invasive bladder cancer (MIBC). In some embodiments, the urothelial carcinoma of the lower urinary tract is non-muscle-invasive bladder cancer (NMBIC).

[0054] As used herein, the term "sustained" or "sustainedly" refers to the administration of an antimetabolite (e.g., gemcitabine) over a period of time, e.g., over a period of 24 hours to 3 weeks.

[0055] As used herein, the term "individual" refers to a mammal, including a human. Individuals include, but are not limited to, humans, cows, horses, cats, dogs, rodents or primates. In some embodiments, the individual is a human.

[0056] As used herein, reference to a "about" value or parameter includes (and describes) embodiments that relate to that value or parameter itself. For example, "about 7 days" includes 7 days.

[0057] These methods can be carried out in an adjuvant setting. An "adjuvant setting" refers to a clinical situation in which an individual has a history of a proliferative disease, particularly cancer, and is generally (but not necessarily) responsive to treatments including, but not limited to, surgery (e.g., surgical resection), radiation therapy, and chemotherapy. However, due to a history of a proliferative disease (e.g., cancer), these individuals are considered to be at risk of disease development. Treatment or administration in an "adjuvant setting" refers to a subsequent treatment modality. The degree of risk (i.e., whether an individual in an adjuvant setting is considered "high risk" or "low risk") depends on several factors, most commonly the extent of the disease at the time of initial treatment. The methods provided herein can also be carried out in a neoadjuvant setting, i.e., the method can be carried out prior to primary / definitive treatment. In some embodiments, the individual has been previously treated. In some embodiments, the individual has not been previously treated. In some embodiments, the treatment is a first-line treatment.

[0058] As used herein, the term "effective amount" refers to an amount of a compound or composition that is sufficient to treat a specified disorder, condition or disease, e.g., to alleviate, mitigate, reduce, and / or delay one or more of its symptoms. With respect to cancer or other undesirable cell growth, an effective amount includes an amount sufficient to shrink a tumor and / or reduce the rate of tumor growth (e.g., inhibit tumor growth), or to prevent or delay other undesirable cell growth. In some embodiments, an effective amount is an amount sufficient to delay development. In some embodiments, an effective amount is an amount sufficient to prevent or delay onset and / or recurrence. An effective amount may be administered in one or more administrations in the case of cancer, and the effective amount of the drug or composition can: (i) reduce the number of cancer cells; (ii) reduce the tumor size; (iii) inhibit, slow down, decelerate, preferably stop, to some extent, the invasion of cancer cells into peripheral organs; (iv) inhibit tumor metastasis (i.e., slow down, preferably stop, to some extent); (v) inhibit tumor growth; (vi) prevent or delay the onset and / or recurrence of tumors; and / or (vii) reduce one or more of the symptoms associated with cancer to some extent.

[0059] In some embodiments, a method of reducing disease progression is provided, the method comprising delivering to an individual an effective amount of an antimetabolite (e.g., a nucleoside analog, e.g., gemcitabine), wherein the antimetabolite (e.g., a nucleoside analog, e.g., gemcitabine) is delivered locally to the bladder. In some embodiments, a method of reducing tumor volume is provided, the method comprising delivering to an individual an effective amount of an antimetabolite (e.g., a nucleoside analog, e.g., gemcitabine), wherein the antimetabolite (e.g., a nucleoside analog, e.g., gemcitabine) is delivered locally to the bladder. In some embodiments, a method of treating bladder cancer is provided, the method comprising delivering to an individual an effective amount of an antimetabolite (e.g., a nucleoside analog, e.g., gemcitabine), wherein the antimetabolite (e.g., a nucleoside analog, e.g., gemcitabine) is delivered locally to the bladder and no residual outwardly growing tumor is present after treatment.

[0060] In some embodiments, the methods provided herein are useful for improving the quality of life of a patient. For example, the methods provided herein can be used to provide chronic treatment to patients who are not candidates for cystectomy. In some embodiments, the methods provided herein can be used as palliative care. In some embodiments, a method of reducing pain in an individual having cancer is provided herein.

[0061] In some embodiments, a method of sensitizing an individual having urothelial carcinoma of the lower urinary tract for radiotherapy is provided, the method comprising delivering to the individual an effective amount of an antimetabolite (e.g., a nucleoside analog, e.g., gemcitabine), wherein the antimetabolite (e.g., a nucleoside analog, e.g., gemcitabine) is delivered locally to the bladder. In some embodiments, the method further comprises subjecting the individual to radiotherapy. In some embodiments, radiotherapy is performed after delivery of the antimetabolite, for example, on any of about 1, 2, 3, 4, 5, 10, 15, 20, or 30 days after delivery of the antimetabolite. Radiations contemplated herein include, for example, X-rays, gamma rays, and direct delivery of radioisotopes to tumor cells. Other forms of DNA damaging agents, such as microwaves and UV irradiation are also contemplated. The radiation can be delivered in a single dose or in a series of smaller doses in a fractionated schedule. In some embodiments, the dose of radiation is lower than conventional doses for radiotherapy. For example, the dose of radiation can be any of about 95%, 90%, 85%, 80%, 75%, 60%, 50%, 40%, 30%, 20%, or 10% or less of the conventional dose.

[0062] The antimetabolite is, in some embodiments, delivered continuously into the bladder. For example, in some embodiments, the antimetabolite is delivered continuously to the bladder for at least about 24 hours (e.g., for at least about 2, 3, 4, 5, 6, 7, 8, 9, 10, 15, 20, 25, or 30 days). In some embodiments, the antimetabolite is delivered continuously to the bladder for 7 days. The antimetabolite can be delivered at a single release rate or at different release rates at different times. For example, in some embodiments, the antimetabolite is delivered at a first release rate during a first period of delivery, followed by a second period of delivery having a second release rate. In some embodiments, the first release rate is faster (e.g., at least 2×, 3×, 4×, 5×, or 10× faster) than the second release rate. In some embodiments, the first rate is slower (e.g., at least 2×, 3×, 4×, 5×, or 10× slower) than the second release rate.

[0063] In some embodiments, the antimetabolite is delivered at any dose from about 1 mg / day to about 300 mg / day, such as from about 1 mg / day to about 5 mg / day, from about 5 mg / day to about 10 mg / day, from about 10 mg / day to about 50 mg / day, from about 50 mg / day to about 100 mg / day, from about 100 mg / day to about 225 mg / day (e.g., about 140 mg, about 160 mg, about 180 mg, about 200 mg or about 220 mg), from about 200 mg / day to about 300 mg / day. In some embodiments, about 100 mg to about 200 mg of gemcitabine is delivered to the individual. In some embodiments, about 160 mg of gemcitabine is delivered to the individual over 7 days. In some embodiments, about 100 mg to about 200 mg of gemcitabine is delivered to the individual over 7 days. In some embodiments, about 200 mg to about 225 mg of gemcitabine is delivered to the individual over 21 days. In some embodiments, about 225 mg of the antimetabolite is delivered to the individual over 21 days. In some embodiments, 225 mg of gemcitabine is administered to the individual over 7 days. In some embodiments, 225 mg of gemcitabine is administered to the individual over 21 days.

[0064] In some embodiments, the concentration of the antimetabolite in urine during the delivery period is from about 0.1 μg / mL to about 200 μg / mL, for example, any one of about 0 - 0.5, 0.5 - 1, 1 - 2, 2 - 3, 3 - 4, 4 - 5, 5 - 6, 6 - 7, 7 - 8, 8 - 9, 9 - 10, 10 - 20, 20 - 30, 30 - 40, 40 - 60, 60 - 80, 80 - 100, 100 - 150 or 150 - 200 μg / mL. In some embodiments, the concentration of the antimetabolite in the plasma of the individual is less than about 1 μg / mL, for example, less than any one of about 0.5, 0.4, 0.3, 0.2, 0.1, 0.05, 0.04, 0.03, 0.02 or 0.01 μg / mL. In some embodiments, at the time of delivery of the antimetabolite, the ratio of the antimetabolite in the urine of the individual to the antimetabolite in the plasma is greater than about 500:1. In some embodiments, the plasma concentration of dFdU is less than 0.3 μg / mL at the time of delivery of the antimetabolite. In some embodiments, the plasma concentration of dFdU is less than 0.2 μg / mL at the time of delivery of the antimetabolite. In some embodiments, the plasma concentration of dFdU is less than 0.1 μg / mL at the time of delivery of the antimetabolite. In some embodiments, the plasma concentration of dFdU is between 0.1 μg / mL and 0.3 μg / mL at the time of delivery of the antimetabolite.

[0065] In some embodiments, the delivery of the antimetabolite comprises separate antimetabolite delivery periods with a drug-free period therebetween. The dosage or release rate of the antimetabolite during different delivery periods may be the same or different. For example, in some embodiments, the antimetabolite is delivered over at least 1 month, each antimetabolite delivery period is at least 1 day, and the interval between each antimetabolite delivery period is about 1 week or less. In some embodiments, the method comprises: a) a first antimetabolite delivery period during which the concentration of the antimetabolite in the urine of the individual is at least about 0.1 μg / mL; b) a drug-free period; and c) a second antimetabolite gemcitabine delivery period during which the concentration of the antimetabolite in the urine of the individual is higher than about 0.1 μg / mL. In some of these embodiments, the first antimetabolite delivery period is 7 days, the drug-free period is 14 days, and the second antimetabolite delivery period is 7 days. In some embodiments, the antimetabolite is delivered on days 1 - 7 and 21 - 28 of the treatment regimen. In some embodiments, the antimetabolite is delivered on days 1 - 14 and 22 - 34.

[0066] In some embodiments, the method comprises two or more delivery periods that are not separated by a drug-free period. In some of these embodiments, the first and second delivery periods are both 3 weeks. In some embodiments, the antimetabolite is delivered over a 6-week period.

[0067] In some embodiments, the antimetabolite persists even after the cessation of delivery. For example, in some embodiments, the concentration of the antimetabolite in the urine is higher than about 0.1 μg / mL (e.g., higher than any of about 0.2, 0.3, 0.4, 0.5, 0.6, 0.7, 0.8, 0.9, or 1 μg / mL) for at least about 6, 12, 18, 24, or 36 hours after the cessation of antimetabolite delivery. In some embodiments, the concentration of the antimetabolite is from 0.1 - 1 μg / mL, 0.2 - 0.8 μg / mL, or 0.3 - 0.7 μg / mL over a period of 6 hours to 7 days, 6 hours to 3 days, or 6 hours to 24 hours.

[0068] Various methods can be used to evaluate the anti-tumor effects produced by the methods provided herein. For example, the levels of biomarkers such as AKT, CD31, Ki67, and TUNEL can be measured in tumor materials using immunohistochemistry to evaluate cell death.

[0069] The methods described herein are particularly suitable, for example, for combination therapies in conjunction with the delivery of a second agent. For example, in some embodiments, a method of treating urothelial carcinoma of the lower urinary tract in an individual, comprising: a) delivering to the individual an effective amount of an antimetabolite (e.g., a nucleoside analog, e.g., gemcitabine), and b) delivering to the individual an effective amount of a second agent, wherein the antimetabolite (e.g., a nucleoside analog, e.g., gemcitabine) is delivered locally to the bladder, is provided. In some embodiments, the second agent is delivered at the time when delivery of the antimetabolite is initiated. In some embodiments, the second agent is delivered before delivery of the antimetabolite is initiated. In some embodiments, the second agent is delivered after delivery of the antimetabolite has been initiated. In some embodiments, the second agent is delivered after delivery of the antimetabolite has been terminated. The antimetabolite delivery period and the second agent delivery period may or may not overlap with each other.

[0070] The antimetabolite and the second agent can be delivered via different routes. For example, in some embodiments, the second agent is delivered systemically. In some embodiments, the second agent is delivered locally. In some embodiments, the second agent is delivered systemically at a first time of the second agent delivery period, followed by local delivery at a second time of the second agent delivery period. In some embodiments, the second agent is delivered locally at a first time of the second agent delivery period, followed by systemic delivery at a second time of the second agent delivery period. The first time of the second agent delivery period and the second time of the second agent delivery period can, in some embodiments, be separated by, for example, any of at least about 1, 2, 3, 4, 5, 6, or 7 days. In some embodiments, the first time of the second agent delivery period and the second time of the second agent delivery period can, in some embodiments, be separated by any of at least about 1, 2, 3, 4, 5, 6, or 7 weeks.

[0071] In some embodiments, the antimetabolite and the second agent are delivered simultaneously via either the same or different administration routes.

[0072] In some embodiments, the antimetabolite and the second agent are delivered via a single delivery device, such as any of the delivery devices described herein. For example, the device can include two separate chambers, one for the antimetabolite and the other for the second agent. Alternatively, the antimetabolite and the second agent are, for example, mixed with each other and present in the same chamber. In some embodiments, the antimetabolite and the second agent are delivered at the same release rate. In some embodiments, the antimetabolite and the second agent are delivered at different release rates. Different release rates can be achieved, for example, by employing a delivery device of a specific design to adjust the drug delivery profile. In some embodiments, when the antimetabolite and the second agent are delivered simultaneously (e.g., via the same delivery device), the method can further include the administration of an additional dose of the second agent. This can be achieved, for example, by systemic or local delivery of the second agent.

[0073] The second agent can be any therapeutic agent suitable for the methods described herein. In some embodiments, the second agent is a chemotherapeutic agent selected from the group consisting of chemotherapeutic agents such as paclitaxel, docetaxel, carboplatin, cisplatin, and oxaliplatin.

[0074] In some embodiments, provided herein are methods of treating urothelial carcinoma of the lower urinary tract, the method comprising the step of locally administering an antimetabolite (e.g., gemcitabine) in combination with BCG to the bladder. In some of these embodiments, the method comprises the step of locally delivering gemcitabine to the bladder of an individual over a period of 24 hours to 3 weeks and the step of administering BCG. In some embodiments, provided herein does not include the step of administering BCG to an individual in combination with gemcitabine.

[0075] In some embodiments, the second agent is an immunomodulatory agent. For example, in some embodiments, a method of treating urothelial carcinoma of the lower urinary tract in an individual, comprising the steps of administering to the individual a) an effective amount of an antimetabolite (e.g., a nucleoside analog, e.g., gemcitabine) and b) an effective amount of an immunomodulatory agent, wherein the antimetabolite (e.g., a nucleoside analog, e.g., gemcitabine) is delivered locally to the bladder, is provided. In some embodiments, the immunomodulatory agent is an immune checkpoint inhibitor including, but not limited to, an inhibitor of an immune checkpoint protein selected from the group consisting of PD-L1, CTLA4, PD-L2, PD-1, B7-H3, B7-H4, HVEM, B and T lymphocyte attenuator (BTLA), killer inhibitory receptor (KIR), GAL9, TIM3, A2AR, LAG-3, phosphatidylserine, CD27, TNF-α, CD33, Siglec-5, Siglec-7, Siglec-9, and Siglec-11. In some embodiments, the immunomodulatory agent is an agonist of a costimulatory immune molecule including, but not limited to, a costimulatory immune molecule selected from the group consisting of CD40, OX40, ICOS, CD28, CD137 / 4-1BB, CD27, IL-10, TGF-beta, TOR receptor, and glucocorticoid-induced TNFR-related protein GITR.

[0076] In some embodiments, the individual does not receive radiation therapy. In some embodiments, the method further comprises radiation therapy. In some embodiments, the antimetabolite is delivered in a neoadjuvant setting. In some embodiments, the antimetabolite is delivered in an adjuvant setting. In some embodiments, the method further comprises a third treatment including surgery, and the delivery of the antimetabolite to the individual can be initiated at the time of surgery, before surgery, or after surgery. In some embodiments, the delivery of the antimetabolite to the individual is initiated during cystoscopy.

[0077] The delivery of the antimetabolite (and, in some embodiments, the second agent) described herein can, in some embodiments, be effected using an intravesical (intra - bladder) delivery device. Various intravesical (intra - bladder) delivery devices are described herein. In some embodiments, the intravesical (intra - bladder) device includes a housing configured for intravesical (intra - bladder) insertion; and a dosage form containing the antimetabolite, the housing being configured to hold the dosage form and release the antimetabolite in an amount effective for the treatment of urothelial cancer. In some embodiments, the intravesical (intra - bladder) drug delivery device includes a housing that contains the antimetabolite, controllably releases it, and is elastically deformable between a retention shape configured to hold the device in an individual's bladder and a deployment shape for passage of the device through the individual's urethra. In some embodiments, the device includes a drug reservoir lumen bounded by a first wall (e.g., a cylindrical wall) and a second wall (e.g., a disk - shaped wall), the first wall being impermeable to the drug and the second wall being permeable to the antimetabolite. In some other embodiments where the first wall is impermeable to the antimetabolite and the second wall is permeable to the antimetabolite, the first wall and the second wall are adjacent to each other and together form an annular tube defining the drug reservoir lumen. In some of these embodiments, the second wall is in the form of a strip extending over at least a portion of the length of the structure of the first wall. In some embodiments, the device includes at least two drug reservoir lumens, and in some embodiments, each reservoir contains a different drug contained therein.

[0078] The antimetabolite can be released from the device by osmotic pressure or diffusion, depending on the desired drug release profile. In some embodiments, the antimetabolite contained in the housing is in a non - liquid form, and for example, the non - liquid form is selected from the group consisting of tablets, granules, semi - solids, powders, capsules, and combinations thereof. Various non - liquid forms of the drug core are further described herein.

[0079] In some embodiments, the antimetabolite is delivered via passive transport. In some embodiments, the passive transport is facilitated transport.

[0080] In some embodiments, urothelial carcinoma of the lower urinary tract is bladder cancer. For example, in some embodiments, a method of treating bladder cancer in an individual comprising the step of administering to the individual a) an effective amount of an antimetabolite (e.g., a nucleoside analog, e.g., gemcitabine), and optionally b) an effective amount of a second agent (e.g., an immunomodulatory agent), wherein the antimetabolite (e.g., a nucleoside analog, e.g., gemcitabine) is delivered locally to the bladder, is provided. In some embodiments, the bladder cancer is locally advanced bladder cancer or metastatic bladder cancer. In some embodiments, the bladder cancer is muscle-invasive bladder cancer. In some embodiments, the bladder cancer is non-muscle-invasive bladder cancer. In some embodiments, the bladder cancer is carcinoma in situ. In some embodiments, the bladder cancer is BCG (Bacillus Calmette-Guerin)-refractory cancer or papillary bladder cancer.

[0081] The individual described herein can be a mammal, preferably a human. In some embodiments, the individual is unsuitable for systemic treatment. In some embodiments, the individual has a compromised immune system. In some embodiments, the individual is resistant or unsuitable for chemotherapeutic treatment. In some embodiments, the individual is resistant or unsuitable for other cancer immunotherapies. In some embodiments, the individual has a low neutrophil count. In some embodiments, the individual is ineligible for cisplatin-based combination therapy. In some embodiments, the individual has not received prior radiation therapy to the bladder. In some embodiments, the individual is averse to or unable to undergo a cystectomy. In some embodiments, the individual may undergo a cystectomy after treatment with the antimetabolite.

[0082] In some embodiments, the level of an immune checkpoint protein is used as a basis for selecting an individual for treatment using the methods described herein. In some embodiments, the individual has a high level of an immune checkpoint protein (e.g., PD-L1). In some embodiments, the individual has a low level of an immune checkpoint protein (e.g., PD-L1). In some embodiments, the individual is selected for treatment based on the level of an immune checkpoint protein (e.g., PD-L1). In some embodiments, the individual is selected for treatment if it is determined that the individual has a high level of an immune checkpoint protein (e.g., PD-L1). In some embodiments, the individual is selected for treatment if the individual has a low level of an immune checkpoint protein (e.g., PD-L1).

[0083] In some embodiments, the level of a nucleoside transporter is used as a basis for selecting an individual for treatment using the methods described herein. In some embodiments, the individual has a high level of a nucleoside transporter (e.g., hENT1). In some embodiments, the individual has a low level of a nucleoside transporter (e.g., hENT1). In some embodiments, the individual is selected for treatment based on the level of a nucleoside transporter (e.g., hENT1). In some embodiments, the individual is selected for treatment if it is determined that the individual has a high level of a nucleoside transporter (e.g., hENT1). In some embodiments, the individual is selected for treatment if the individual has a low level of a nucleoside transporter (e.g., hENT1).

[0084] The effectiveness of the methods described herein can be evaluated by various methods. For example, for methods of treatment, the effectiveness of the method can be evaluated by tumor growth, tumor shrinkage, or survival. In some embodiments, the effectiveness of the method is evaluated based on the level of one or more markers. For example, the effectiveness of the method can be determined based on the level of TGF-beta or IL-10. In some embodiments, the effectiveness of the method can be evaluated based on the ratio of antimetabolites and their metabolites in urine. For example, if the antimetabolite is gemcitabine, the effectiveness of the method can be evaluated based on the ratio of gemcitabine and its metabolite (e.g., dFdU) in urine. For cancer treatment, a ratio below a threshold can indicate effectiveness.

[0085] In some embodiments, pro-inflammatory cytokine production can increase and anti-inflammatory cytokine production can decrease. The amount of pro-inflammatory cytokines can increase locally in the bladder or systemically, and similarly, the amount of anti-inflammatory cytokines can decrease locally in the bladder or systemically. For example, in some embodiments, the level of IL-10 increases. In some embodiments, the level of TGFβ decreases. In some embodiments, the level of interferon gamma (IFN-γ) increases.

[0086] Regulatory T cells, also known as suppressor T cells or T-regs, are an immunosuppressive population of T cells. In cancer, regulatory T cells are recruited to the tumor microenvironment, suppress effector T cells, and provide an immunosuppressive tumor microenvironment that reduces the body's immune response to the tumor. Regulatory T cells carry out their immunosuppressive functions through the cellular secretion of anti-inflammatory cytokines.

[0087] Accordingly, in one embodiment, the method promotes the treatment of urothelial carcinoma of the lower urinary tract by reducing the number, level or percentage of regulatory T cells upon administration of an antimetabolite (e.g., a nucleoside analog, such as gemcitabine). Those skilled in the art will recognize various methods for measuring the presence of regulatory T cells in a sample, such as immunohistochemically staining for relevant markers or performing flow cytometry or FACS analysis. The level or percentage of regulatory T cells can also be relatively decreased compared to conventional T cells that are CD4+CD25-.

[0088] Furthermore, or alternatively, the activity of regulatory T cells can be decreased upon delivery of the antimetabolite. Functional assays, such as cytokine release, can be used to measure the activity of regulatory T cells.

[0089] The number, level, amount or activity of regulatory T cells can be decreased locally, for example, in the bladder, tumor microenvironment, or local lymph nodes. The number, level, amount or activity of regulatory T cells can also be decreased systemically.

[0090] Cytotoxic T cells are CD8+ T cells that recognize targets by binding to antigens associated with MHC class I molecules. Cytotoxic T cells are recognized to play an important role in the body's anti-cancer response by recognizing infected or damaged cells and inducing their apoptosis via the caspase cascade. Upon delivery of the antimetabolite, the level, number and / or activity of cytotoxic T cells can increase to promote the body's anti-cancer response. For example, the relative level of cytotoxic T cells can increase compared to inhibitory regulatory T cells, which can be determined by FACS analysis. Furthermore, or alternatively, the activity of cytotoxic T cells can increase, which can be measured using a functional assay.

[0091] Activated effector CD4+ T cells also play an important role in generating an inflammatory response by secreting pro-inflammatory cytokines, proteins or peptides, and are recognized to play an important role in the body's anti-cancer response. Upon delivery of the metabolic antagonist, the levels, numbers and / or activity of effector CD4+ T cells can be increased to promote the body's anti-cancer response. For example, the relative level of effector CD4+ T cells can be increased compared to that of inhibitory regulatory T cells, which can be determined by FACS analysis. Additionally, or alternatively, the activity of effector CD4+ T cells can be increased, which can be measured using a functional assay.

[0092] In some embodiments, the level of regulatory T cells is decreased compared to the levels of both cytotoxic T cells and effector T cells. In some embodiments, the level of regulatory T cells is decreased compared to the level of activated conventional CD4+ / CD25− T cells (Tcon). Immune checkpoint inhibitor

[0093] Immunomodulatory agents can be agents that modulate checkpoint inhibitors. Immune checkpoint proteins are signaling proteins that play a role in regulating the immune response. Some checkpoint inhibitors are receptors located on the surface of cells that respond to extracellular signaling. For example, many checkpoints are initiated by ligand-receptor interactions. When activated, checkpoint proteins can generate an anti-inflammatory response that can include the activation of regulatory T cells and the inhibition of cytotoxic or killer T cells. Cancer cells have been shown to express checkpoint proteins as a way to evade recognition by immune cells. Thus, checkpoint inhibitors can be used to activate the immune system in an individual to kill cancer cells. Pardoll, Nature Reviews Cancer 12, 252-264 (2012).

[0094] Exemplary checkpoint inhibitors include inhibitors of PD-L1, CTLA4, PD-L2, PD-1, B7-H3, B7-H4, HVEM, B and T lymphocyte attenuator (BTLA), killer inhibitory receptor (KIR), GAL9, TIM3, A2AR, LAG-3, phosphatidylserine, CD27, TNF-α, CD33, Siglec-5, Siglec-7, Siglec-9, and Siglec-11.

[0095] CTLA-4 signaling inhibits T cell activation, particularly during strong T cell responses. CTLA-4 blockade using CTLA-4 inhibitors such as anti-CTLA-4 monoclonal antibodies is more attractive because suppression of the inhibitory signal results in the generation of anti-tumor T cell responses. Both clinical and preclinical data have shown that CTLA-4 blockade results in the direct activation of CD4+ and CD8+ effector cells, and anti-CTLA-4 monoclonal antibody therapy has shown promise in several cancers, particularly melanoma. Leach et al., Science, 271:1734-1736 (1996); Wolchok et al., Oncologist, 13(Suppl 4):2-9 (2008).

[0096] Similar to CTLA-4 signaling, PD-1 / PD-L1 modulates T cell responses. Tregs expressing PD-1 have been shown to have immunosuppressive responses, and thus PD-1 / PD-L1 expression is thought to play a role in self-tolerance. With respect to cancer, tumor cells overexpress PD-1 and PD-L1 to escape recognition by the immune system. Anti-cancer therapy that blocks PD-L1 / PD-1 increases effector T cell activity and decreases inhibitory Treg activity, enabling the recognition and destruction of tumors by an individual's immune system.

[0097] A variety of checkpoint inhibitors can be used. For example, a checkpoint inhibitor can be an antibody that binds to a checkpoint inhibitor protein and antagonizes it. Exemplary antibodies include anti-PD1 antibodies (nivolumab, pembrolizumab, pidilizumab), anti-PD-L1 antibodies (atezolizumab, BMS-936559, MPDL-3280A, MEDI7436, AMP224), anti-CTLA4 antibodies (ipilimumab, tremelimumab), and the like. In some embodiments, the checkpoint inhibitor antagonist can be a small molecule or RNAi that targets a checkpoint inhibitor. In some embodiments, the checkpoint inhibitor can be a peptide mimetic or polypeptide. Immune co-stimulatory molecule agonist

[0098] Immune modulatory agents can also be immune co-stimulatory molecule agonists. Immune co-stimulatory molecules are signaling proteins that play a role in regulating the immune response. Some immune co-stimulatory molecules are receptors located on the surface of cells that respond to extracellular signaling. When activated, immune co-stimulatory molecules can generate a pro-inflammatory response that includes suppression of regulatory T cells and activation of cytotoxic or killer T cells. Thus, immune co-stimulatory molecule agonists can be used to activate the immune system in an individual to kill cancer cells.

[0099] Exemplary immune co-stimulatory molecules include any of CD40, OX40, ICOS, CD28, CD137 / 4-1BB, CD27, and the glucocorticoid-induced TNFR-related protein GITR. For example, OX40 stimulation enhances the survival and activity of effector T cells while suppressing T reg cell function, thereby increasing anti-tumor immunity.

[0100] A variety of immunostimulatory molecule agonists can be used. For example, an immunostimulatory molecule agonist can be an antibody that binds to and activates an immunostimulatory molecule. In some embodiments, the immunostimulatory molecule can be an agonist antibody against CD40, OX30 or GITR. In further embodiments, the immunostimulatory molecule agonist can be a small molecule that targets and activates an immunostimulatory molecule. Dosing regimen

[0101] The following sections describe various aspects (embodiments) of the dosing and treatment areas, all of which are inclusive and applicable to the methods described herein.

[0102] In some embodiments, the invention includes a method of treating urothelial carcinoma of the lower urinary tract of an individual, the method comprising locally delivering an antimetabolite (e.g., a nucleoside analog, e.g., gemcitabine) to the bladder of the individual. Various methods can be used to deliver the antimetabolite. In one embodiment, the drug can be provided by direct injection of a simple solution into the bladder. For example, the solution of the drug can be pumped into the bladder via the urethra or a suprapubic catheter in a continuous or pulsed manner over the treatment period. In another embodiment, the drug is released from a device or composition placed in the bladder, and the device or composition continuously releases the drug at a rate effective to produce a desired concentration of the drug in the urine over a specified treatment period. For example, the drug can be released from a device inserted into the bladder into the urine in the bladder, and then the drug diffuses from the urine back into the bladder. At the end of the treatment period, the device can be retrieved from the bladder or removed by resorption, dissolution, excretion, or a combination thereof.

[0103] In some embodiments, the antimetabolite (e.g., a nucleoside analog, such as gemcitabine) is delivered continuously to the bladder. In some embodiments, the antimetabolite is delivered continuously into the bladder. In some embodiments, the antimetabolite is delivered continuously into the bladder over a period of at least about 6, at least about 12, at least about 18, at least about 24, at least about 36, at least about 48, at least about 60 or at least about 72 hours. In some embodiments, the antimetabolite is delivered to the bladder over a period of at least about 1 day, at least about 2 days, at least about 3 days, at least about 4 days, at least about 5 days, at least about 6 days, at least about 7 days, at least about 8 days, at least about 9 days, at least about 10 days, at least about 11 days, at least about 12 days, at least about 13 days or at least about 14 days. In some embodiments, the antimetabolite is delivered to the bladder over a period of about 1 day to about 14 days, about 2 days to about 14 days, about 3 days to about 10 days, about 4 days to about 8 days or about 5 days to about 7 days. In some embodiments, the antimetabolite is delivered to the bladder over a period of about 7 days. In some embodiments, gemcitabine is delivered to the bladder over a period of about 1 to about 30 days. In some embodiments, the antimetabolite is delivered to the bladder over a period of about 30 days.

[0104] In some embodiments, provided herein is a method comprising delivering gemcitabine to the bladder on days 1-7 and 21-28 of a treatment regimen.

[0105] In some embodiments, the antimetabolite is delivered continuously into the urine of the bladder.

[0106] In some embodiments, an effective amount of the metabolic antagonist is delivered locally to the bladder of an individual. For example, the metabolic antagonist can be delivered at a dosage of about 1 mg / day to about 300 mg / day. In some embodiments, the metabolic antagonist is delivered at a dosage of about 5 mg / day to about 250 mg / day, about 10 mg / day to about 200 mg / day, about 15 mg / day to about 100 mg / day or about 15 mg / day to about 50 mg / day. In some embodiments, the metabolic antagonist is delivered at a dosage of about 1 mg / day, about 5 mg / day, about 10 mg / day, about 15 mg / day, about 20 mg / day, about 23 mg / day, about 25 mg / day, about 30 mg / day, about 35 mg / day, about 40 mg / day, about 45 mg / day, about 50 mg / day, about 55 mg / day, about 60 mg / day, about 75 mg / day, about 100 mg / day, about 125 mg / day, about 150 mg / day, about 200 mg / day, about 250 mg / day or about 300 mg / day.

[0107] The total amount of the metabolic antagonist delivered to the individual during the delivery period can range from about 50 mg to about 1000 mg, about 75 mg to about 750 mg, about 100 mg to about 500 mg, about 200 mg to about 400 mg or about 100 mg to about 200 mg. In some embodiments, about 225 mg of the metabolic antagonist is delivered to the individual. In some embodiments, about 100 - about 225 mg of gemcitabine (e.g., about 140 mg, about 160 mg, about 180 mg, about 200 mg or about 220 mg of the metabolic antagonist) is delivered to the individual over 7 days. In some embodiments, about 100 - about 225 mg of gemcitabine (e.g., about 140 mg, about 160 mg, about 180 mg, about 200 mg or about 220 mg of the metabolic antagonist) is delivered to the individual over 3 weeks. In some embodiments, about 100 - about 225 mg of gemcitabine (e.g., about 140 mg, about 160 mg, about 180 mg, about 200 mg or about 220 mg of gemcitabine) is administered to the individual over 3 weeks. In some embodiments, 225 mg of gemcitabine is administered to the individual over 7 days. In some embodiments, 225 mg of gemcitabine is administered to the individual over 3 weeks.

[0108] In some embodiments, the concentration of the antimetabolite in urine is from about 0.1 μg / mL to about 200 μg / mL during the antimetabolite delivery period. In some embodiments, the concentration of the antimetabolite in urine is from about 1.0 μg / mL to about 100 μg / mL, from about 5.0 μg / mL to about 90 μg / mL, from about 10 μg / mL to about 80 μg / mL, from about 20 μg / mL to about 70 μg / mL, or from about 30 μg / mL to about 50 μg / mL. In some embodiments, the concentration of the antimetabolite in urine is about 1.0 μg / mL, about 5 μg / mL, about 10 μg / mL, about 15 μg / mL, about 20 μg / mL, about 25 μg / mL, about 30 μg / mL, about 40 μg / mL, about 50 μg / mL, about 60 μg / mL, about 70 μg / mL, about 80 μg / mL, about 90 μg / mL, or about 100 μg / mL.

[0109] The concentration of the antimetabolite in urine can vary depending on the amount of urine in the bladder over the course of the bladder excretion cycle. For example, after the contents of the bladder have been excreted, the concentration of the antimetabolite in urine can be from about 50 μg / mL to about 100 μg / mL. On the other hand, immediately prior to excretion, the concentration of the antimetabolite in urine can be lower, for example, from about 0.1 μg / mL to about 10 μg / mL. In some embodiments, the average concentration of the antimetabolite over the excretion cycle is about 1.0 μg / mL, about 5 μg / mL, about 10 μg / mL, about 15 μg / mL, about 20 μg / mL, about 25 μg / mL, about 30 μg / mL, about 40 μg / mL, about 50 μg / mL, about 60 μg / mL, about 70 μg / mL, about 80 μg / mL, about 90 μg / mL, or about 100 μg / mL. In some variations, the maximum concentration of the antimetabolite over the excretion cycle is from about 25 μg / mL to about 250 μg / mL, from about 50 μg / mL to about 200 μg / mL, or from about 100 μg / mL to about 200 μg / mL. In some embodiments, the minimum concentration of the antimetabolite over the excretion cycle is from about 0.1 μg / mL to about 20 μg / mL, from about 0.1 μg / mL to about 10 μg / mL, or from about 1 μg / mL to about 5 μg / mL.

[0110] One advantage of the methods provided herein is that a therapeutically effective amount of the antimetabolite persists in the urine after delivery of the antimetabolite has ended. For example, in some embodiments, the concentration of the antimetabolite in the urine is greater than about 1 μg / mL for at least about 1 day, at least about 2 days, at least about 3 days, at least about 4 days, at least about 5 days, at least about 6 days, at least about 7 days, at least about 8 days, at least about 9 days, at least about 10 days, at least about 11 days, at least about 12 days, at least about 13 days, or at least about 14 days after delivery of the antimetabolite has ended. In some embodiments, the concentration of the antimetabolite in the urine is greater than about 1 μg / mL for between 1 day and 14 days, between 1 day and 10 days, between 2 days and 9 days, or between 3 days and 8 days. In some embodiments, the concentration of the antimetabolite in the urine is greater than about 5 μg / mL for at least about 1 day, at least about 2 days, at least about 3 days, at least about 4 days, at least about 5 days, at least about 6 days, at least about 7 days, at least about 8 days, at least about 9 days, at least about 10 days, at least about 11 days, at least about 12 days, at least about 13 days, or at least about 14 days after delivery of the antimetabolite has ended. In some embodiments, the concentration of the antimetabolite in the urine is greater than about 5 μg / mL for between 1 day and 14 days, between 1 day and 10 days, between 2 days and 9 days, or between 3 days and 8 days. In some embodiments, the concentration of the antimetabolite in the urine is greater than about 10 μg / mL for at least about 1 day, at least about 2 days, at least about 3 days, at least about 4 days, at least about 5 days, at least about 6 days, at least about 7 days, at least about 8 days, at least about 9 days, at least about 10 days, at least about 11 days, at least about 12 days, at least about 13 days, or at least about 14 days after delivery of the antimetabolite has ended. In some embodiments, the concentration of the antimetabolite in the urine is greater than about 1 μg / mL for between 1 day and 14 days, between 1 day and 10 days, between 2 days and 9 days, or between 3 days and 8 days after delivery of the antimetabolite has ended.

[0111] Another advantage of the methods provided herein is that the antimetabolite is delivered locally to the bladder of the individual such that a significant amount of the antimetabolite is not present in the plasma of the individual. In some embodiments, the concentration of the antimetabolite in the plasma of the individual is less than about 5 μg / mL, less than about 3 μg / mL, less than about 1 μg / mL, less than about 0.5 μg / mL, less than about 0.1 μg / mL, less than about 0.001 μg / mL, or less than about 0.0001 μg / mL.

[0112] Since the antimetabolite is delivered locally to the bladder, the concentration of the antimetabolite present in the urine of the individual is higher than that in the plasma during delivery of the antimetabolite, which can be beneficial for reducing side effects of the antimetabolite. For example, local delivery of the antimetabolite to the bladder can result in reduced neutropenia, lymphedema, anemia, thrombocytopenia, fatigue, pain, hair loss, reproductive dysfunction, or memory impairment caused by systemic chemotherapy. For example, in some embodiments, the ratio of the concentration of the antimetabolite in the urine of the individual to the concentration of the antimetabolite in the plasma of the individual is greater than about 100:1, greater than about 200:1, greater than about 300:1, greater than about 400:1, greater than about 500:1, greater than about 600:1, greater than about 700:1, or greater than about 1000:1.

[0113] It may be advantageous to deliver the metabolic antagonist locally to the bladder more than once. For example, in some embodiments, the metabolic antagonist is delivered locally to the bladder of an individual at least 2 times, at least 3 times, at least 4 times, at least 5 times or at least 10 times. In some embodiments, the metabolic antagonist is delivered multiple times over a period of at least 2 weeks, at least 3 weeks, at least 4 weeks, at least 5 weeks, at least 6 weeks or at least 8 weeks. In some embodiments, the metabolic antagonist is delivered multiple times over a period of at least 1 month, at least 2 months, at least 3 months, at least 4 months, at least 5 months, at least 6 months, at least 12 months or at least 18 months. For example, in some embodiments, the metabolic antagonist is delivered locally to the bladder of an individual 2 times, 3 times, 4 times, 5 times or 10 times. In some embodiments, the metabolic antagonist is delivered multiple times over a period of 1 month, from 1 month to 18 months, from 2 months to 18 months, from 3 months to 18 months, from 1 month to 6 months or from 1 month to 2 months. In some embodiments, the metabolic antagonist is delivered locally to the bladder 4 times. In some of these embodiments, the metabolic antagonist is delivered locally to the bladder of an individual 4 times, and each metabolic antagonist delivery period is 3 weeks. In some embodiments, the metabolic antagonist is delivered locally to the bladder of an individual over 12 weeks.

[0114] In some embodiments, the antimetabolite is delivered multiple times over at least one month, and each antimetabolite delivery period is at least one day. In some embodiments, the antimetabolite is delivered at least twice over a period of at least one month. In some embodiments, the antimetabolite is delivered at least three times over a period of at least one month. In some embodiments, the antimetabolite is delivered at least three times over a period of at least one month. In some embodiments, the antimetabolite is delivered at least four times over a period of at least two months. In some embodiments, the interval (drug holiday) between each delivery period of the antimetabolite is about 4 weeks or less, about 3 weeks or less, about 2 weeks or less, or about 1 week or less. In some embodiments, the antimetabolite is delivered over at least one month, each delivery period of the antimetabolite is at least one day, and the interval (drug holiday) between each delivery period is about 1 week or less. In some embodiments, the interval (drug holiday) between each delivery period is 3 to 50 days, 3 to 30 days, 5 to 20 days, or 8 to 15 days. In some embodiments, the drug holiday is at most 4 months (e.g., 1 month, 2 months, 3 months, or 4 months).

[0115] In one aspect, the periods of antimetabolite delivery can be separated by drug holidays, during which the antimetabolite is not delivered. For example, in some embodiments, the method includes a first antimetabolite delivery period; a drug holiday after the first antimetabolite delivery period; and a second delivery period after the drug holiday. In some embodiments, the method includes a 7-day first antimetabolite delivery period; a 14-day drug holiday after the first antimetabolite delivery period; and a 7-day second antimetabolite delivery period. In some embodiments, the method includes a 3-week first antimetabolite delivery period and a subsequent 3-week second antimetabolite delivery period without a drug holiday.

[0116] Provided herein is a method of treating muscle-invasive bladder cancer in an individual, the method comprising the step of locally delivering gemcitabine to the bladder of the individual over a period of 7 days. In some embodiments, provided herein is a method of treating muscle-invasive bladder cancer in an individual, the method comprising the step of locally and continuously delivering gemcitabine to the bladder of the individual over a period of 7 days. In some embodiments, provided herein is a method of treating muscle-invasive bladder cancer in an individual, the method comprising the step of locally and continuously delivering gemcitabine to the bladder of the individual over a period of 7 days, wherein the gemcitabine is delivered by an intravesical (within the bladder) device. In some embodiments, provided herein is a method of treating muscle-invasive bladder cancer in an individual, the method comprising: (i) placing an intravesical (within the bladder) device that releases gemcitabine into the bladder of the individual, wherein the device remains in the bladder for 7 days and the gemcitabine is continuously delivered to the bladder. In some embodiments, provided herein is a method of treating muscle-invasive bladder cancer in an individual, the method comprising: (i) placing an intravesical (within the bladder) device that releases gemcitabine into the bladder of the individual, wherein the device remains in the bladder for 7 days and the intravesical (within the bladder) device that releases gemcitabine passively delivers the gemcitabine. In some embodiments, provided herein is a method of treating muscle-invasive bladder cancer in an individual, the method comprising: (i) on day 0, placing a first intravesical (within the bladder) device that releases gemcitabine into the bladder of the individual; (ii) on day 7, removing the first intravesical (within the bladder) device that releases gemcitabine; (iii) on day 21, placing a second intravesical (within the bladder) device that releases gemcitabine into the bladder of the individual; and (iv) on day 28, removing the second intravesical (within the bladder) device that releases gemcitabine. In some of these embodiments, the device contains 225 mg of gemcitabine prior to placement into the bladder.

[0117] A method of treating muscle-invasive bladder cancer in an individual, the method comprising the step of locally delivering from about 100 to 500 mg of gemcitabine to the bladder over 7 days, is also provided herein. In some embodiments, a method of treating muscle-invasive bladder cancer in an individual, the method comprising the step of locally and continuously delivering from about 100 to about 225 mg of gemcitabine (e.g., about 140 mg, about 160 mg, about 180 mg, about 200 mg, or about 220 mg) to the bladder over 7 days, is provided herein. In some embodiments, a method of treating muscle-invasive bladder cancer in an individual, the method comprising the step of locally and continuously delivering gemcitabine to the individual's bladder over 7 days, wherein the gemcitabine is delivered by an intravesical (within the bladder) device, is provided herein.

[0118] In some embodiments, a method of treating muscle-invasive bladder cancer in an individual, the method comprising: (i) placing an intravesical (within the bladder) device that releases gemcitabine into the individual's bladder, the device remaining in the bladder for 7 days, the device containing 225 mg of gemcitabine, is provided herein. In some embodiments, a method of treating muscle-invasive bladder cancer in an individual, the method comprising: (i) on day 0, placing a first intravesical (within the bladder) device that releases gemcitabine into the individual's bladder, the first gemcitabine-releasing device containing 225 mg of gemcitabine, (ii) on day 7, removing the first intravesical (within the bladder) device that releases gemcitabine, (iii) on day 21, placing a second intravesical (within the bladder) device that releases gemcitabine into the individual's bladder, the second gemcitabine-releasing intravesical (within the bladder) device containing 225 mg of gemcitabine, and (iv) on day 28, removing the second intravesical (within the bladder) device that releases gemcitabine, is provided herein.

[0119] A method of treating muscle-invasive bladder cancer in an individual, the method comprising the step of locally delivering gemcitabine to the bladder of the individual over a three-week period, is provided herein. In some embodiments, a method of treating muscle-invasive bladder cancer in an individual, the method comprising the step of locally and continuously delivering gemcitabine to the bladder of the individual over a three-week period, is provided herein. In some embodiments, a method of treating muscle-invasive bladder cancer in an individual, the method comprising the step of locally and continuously delivering gemcitabine to the bladder of the individual over a three-week period, wherein the gemcitabine is delivered by an intravesical (within the bladder) device, is provided herein.

[0120] In some embodiments, provided herein is a method of treating muscle-invasive bladder cancer in an individual, the method comprising: (i) placing a gemcitabine-releasing intravesical (intra-bladder) device into the bladder of the individual, wherein the gemcitabine-releasing intravesical (intra-bladder) device remains in the bladder for three weeks and gemcitabine is continuously delivered to the bladder. In some embodiments, provided herein is a method of treating muscle-invasive bladder cancer in an individual, the method comprising: (i) placing a gemcitabine-releasing intravesical (intra-bladder) device into the bladder of the individual, wherein the gemcitabine-releasing intravesical (intra-bladder) device remains in the bladder for three weeks and the gemcitabine-releasing intravesical (intra-bladder) device passively delivers gemcitabine. In some embodiments, provided herein is a method of treating muscle-invasive bladder cancer in an individual, the method comprising: (i) placing a first gemcitabine-releasing intravesical (intra-bladder) device into the bladder of the individual, wherein the first gemcitabine-releasing intravesical (intra-bladder) device remains in the bladder for three weeks; (ii) removing the first gemcitabine-releasing intravesical (intra-bladder) device; (iii) placing a second gemcitabine-releasing device into the bladder of the individual three weeks after placing the first gemcitabine-releasing intravesical (intra-bladder) device into the bladder, wherein the second gemcitabine-releasing intravesical (intra-bladder) device remains in the bladder for three weeks; and (iv) removing the second gemcitabine-releasing device.

[0121] A method of treating muscle-invasive bladder cancer in an individual, the method comprising the step of locally delivering more than 225 mg of gemcitabine to the bladder over a period of 3 weeks, is also provided herein. In some embodiments, a method of treating muscle-invasive bladder cancer in an individual, the method comprising the step of locally and continuously delivering more than 225 mg of gemcitabine to the bladder over a period of 3 weeks, is provided herein. In some of these embodiments, about 80% of the gemcitabine is delivered to the bladder in the first week and about 20% of the gemcitabine is delivered to the bladder in the second and third weeks. In some embodiments, a method of treating muscle-invasive bladder cancer in an individual, the method comprising the step of locally and continuously delivering more than 225 mg of gemcitabine to the individual's bladder over a period of 3 weeks, wherein the gemcitabine is delivered by an intravesical (within the bladder) device, is provided herein.

[0122] A method of treating muscle-invasive bladder cancer in an individual, the method comprising the step of locally delivering about 225 mg of gemcitabine to the bladder over a period of 3 weeks, is also provided herein. In some embodiments, a method of treating muscle-invasive bladder cancer in an individual, the method comprising the step of locally and continuously delivering about 225 mg of gemcitabine to the bladder over a period of 3 weeks, is provided herein. In some of these embodiments, about 80% of the gemcitabine is delivered to the bladder in the first week and about 20% of the gemcitabine is delivered to the bladder in the second and third weeks. In some embodiments, a method of treating muscle-invasive bladder cancer in an individual, the method comprising the step of locally and continuously delivering about 225 mg of gemcitabine to the individual's bladder over a period of 3 weeks, wherein the gemcitabine is delivered by an intravesical (within the bladder) device, is provided herein.

[0123] In some embodiments, provided herein is a method of treating muscle-invasive bladder cancer in an individual, the method comprising: (i) placing a gemcitabine-releasing intravesical (intra-bladder) device into the bladder of the individual, the device remaining in the bladder for three weeks, the device containing 225 mg of gemcitabine. In some embodiments, provided herein is a method of treating muscle-invasive bladder cancer in an individual, the method comprising: (i) placing a gemcitabine-releasing intravesical (intra-bladder) device into the bladder of the individual, the device remaining in the bladder for three weeks, the gemcitabine-releasing intravesical (intra-bladder) device passively delivering about 225 mg of gemcitabine. In some embodiments, provided herein is a method of treating muscle-invasive bladder cancer in an individual, the method comprising: (i) placing a first gemcitabine-releasing intravesical (intra-bladder) device into the bladder of the individual, the first gemcitabine-releasing intravesical (intra-bladder) device remaining in the bladder for three weeks, the first gemcitabine-releasing intravesical (intra-bladder) device containing 225 mg of gemcitabine; (ii) removing the first gemcitabine-releasing intravesical (intra-bladder) device; (iii) three weeks after placing the first gemcitabine-releasing intravesical (intra-bladder) device in the bladder, placing a second gemcitabine-releasing device into the bladder of the individual, the second gemcitabine-releasing intravesical (intra-bladder) device remaining in the bladder for three weeks, the second gemcitabine-releasing intravesical (intra-bladder) device containing 225 mg of gemcitabine; and (iv) removing the second gemcitabine-releasing device.

[0124] In some embodiments, provided herein is a method of treating muscle-invasive bladder cancer in an individual, the method comprising: (i) placing a gemcitabine-releasing intravesical (intra-bladder) device into the bladder of the individual, the device remaining in the bladder for three weeks and delivering a total of more than 225 mg of gemcitabine to the bladder in a sustained manner. In some embodiments, provided herein is a method of treating muscle-invasive bladder cancer in an individual, the method comprising: (i) placing a gemcitabine-releasing intravesical (intra-bladder) device into the bladder of the individual, the device remaining in the bladder for three weeks, the gemcitabine-releasing intravesical (intra-bladder) device passively delivering more than 225 mg of gemcitabine. In some embodiments, provided herein is a method of treating muscle-invasive bladder cancer in an individual, the method comprising: (i) placing a first gemcitabine-releasing intravesical (intra-bladder) device into the bladder of the individual, the first gemcitabine-releasing intravesical (intra-bladder) device remaining in the bladder for three weeks and delivering more than 225 mg of gemcitabine to the bladder; (ii) removing the first gemcitabine-releasing intravesical (intra-bladder) device; (iii) three weeks after placing the first gemcitabine-releasing intravesical (intra-bladder) device in the bladder, placing a second gemcitabine-releasing device into the bladder of the individual, the second gemcitabine-releasing intravesical (intra-bladder) device remaining in the bladder for three weeks and delivering more than 225 mg of gemcitabine to the bladder; and (iv) removing the second gemcitabine-releasing device.

[0125] A method of treating non-muscle invasive bladder cancer in an individual, the method comprising the step of locally delivering gemcitabine to the bladder of the individual over a period of 7 days, is provided herein. In some embodiments, a method of treating non-muscle invasive bladder cancer in an individual, the method comprising the step of locally and continuously delivering gemcitabine to the bladder of the individual over a period of 7 days, is provided herein. In some embodiments, a method of treating non-muscle invasive bladder cancer in an individual, the method comprising the step of locally and continuously delivering gemcitabine to the bladder of the individual over a period of 7 days, wherein the gemcitabine is delivered by an intravesical (within the bladder) device, is provided herein. In some embodiments, a method of treating non-muscle invasive bladder cancer in an individual, the method comprising: (i) placing a gemcitabine-releasing intravesical (within the bladder) device into the bladder of the individual, wherein the device remains in the bladder for 7 days and the gemcitabine is continuously delivered to the bladder, is provided herein. In some embodiments, a method of treating non-muscle invasive bladder cancer in an individual, the method comprising: (i) on day 0, placing a first gemcitabine-releasing intravesical (within the bladder) device into the bladder of the individual; (ii) on day 7, removing the first gemcitabine-releasing intravesical (within the bladder) device; (iii) on day 21, placing a second gemcitabine-releasing intravesical (within the bladder) device into the bladder of the individual; and (iv) on day 28, removing the second gemcitabine-releasing intravesical (within the bladder) device, is provided herein.

[0126] A method of treating non-muscle invasive bladder cancer in an individual, the method comprising the step of locally delivering to the bladder about 225 mg of gemcitabine over 7 days, is also provided herein. In some embodiments, a method of treating non-muscle invasive bladder cancer in an individual, the method comprising the step of locally and continuously delivering to the bladder about 100 to about 225 mg of gemcitabine (e.g., about 140 mg, about 160 mg, about 180 mg, about 200 mg, or about 220 mg of gemcitabine) over 7 days, is provided herein. In some embodiments, a method of treating non-muscle invasive bladder cancer in an individual, the method comprising the step of locally and continuously delivering to the individual's bladder over 7 days about 100 to about 225 mg of gemcitabine (e.g., about 140 mg, about 160 mg, about 180 mg, about 200 mg, or about 220 mg of gemcitabine), wherein the gemcitabine is delivered by an intravesical (within the bladder) device, is provided herein.

[0127] In some embodiments, a method of treating non-muscle invasive bladder cancer in an individual, the method comprising: (i) placing an intravesical (within the bladder) device that releases gemcitabine into the individual's bladder, the device remaining in the bladder for 7 days, the device containing 225 mg of gemcitabine, is provided herein. In some embodiments, a method of treating non-muscle invasive bladder cancer in an individual, the method comprising: (i) on day 0, placing a first intravesical (within the bladder) device that releases gemcitabine into the individual's bladder, the first intravesical device that releases gemcitabine containing 225 mg of gemcitabine, (ii) on day 7, removing the first intravesical (within the bladder) device that releases gemcitabine, (iii) on day 21, placing a second intravesical (within the bladder) device that releases gemcitabine into the individual's bladder, the second device that releases gemcitabine containing 225 mg of gemcitabine, and (iv) on day 28, removing the second intravesical (within the bladder) device that releases gemcitabine, is provided herein.

[0128] In some embodiments, the method includes a first antimetabolite delivery period during which the concentration of the antimetabolite in the urine of the individual is higher than about 0.1 μg / mL; a drug withdrawal period after the first antimetabolite delivery period; and a second antimetabolite delivery period after the drug withdrawal period during which the concentration of the antimetabolite in the urine of the individual is higher than about 0.1 μg / mL. In some embodiments, the method includes a first antimetabolite delivery period during which the concentration of the antimetabolite in the urine of the individual is higher than about 5 μg / mL; a drug withdrawal period after the first antimetabolite delivery period; and a second antimetabolite delivery period after the drug withdrawal period during which the concentration of the antimetabolite in the urine of the individual is higher than about 5 μg / mL. In some embodiments, the method includes a first antimetabolite delivery period during which the concentration of the antimetabolite in the urine of the individual is higher than about 7 μg / mL; a drug withdrawal period after the first antimetabolite delivery period; and a second antimetabolite delivery period after the drug withdrawal period during which the concentration of the antimetabolite in the urine of the individual is higher than about 7 μg / mL. In some embodiments, the method includes a first antimetabolite delivery period during which the concentration of the antimetabolite in the urine of the individual is higher than about 10 μg / mL; a drug withdrawal period after the first antimetabolite delivery period; and a second antimetabolite delivery period after the drug withdrawal period during which the concentration of the antimetabolite in the urine of the individual is higher than about 10 μg / mL. In some embodiments, the method includes a first antimetabolite delivery period during which the concentration of the antimetabolite in the urine of the individual is higher than about 15 μg / mL; a drug withdrawal period after the first antimetabolite delivery period; and a second antimetabolite delivery period after the drug withdrawal period during which the concentration of the antimetabolite in the urine of the individual is higher than about 15 μg / mL.

[0129] In some embodiments, the method includes a first antimetabolite delivery period during which the concentration of the antimetabolite in the urine of the individual is from 0.1 to 15 μg / mL; a drug withdrawal period after the first antimetabolite delivery period; and a second antimetabolite delivery period after the drug withdrawal period during which the concentration of the antimetabolite in the urine of the individual is from 0.1 to 15 μg / mL. In some embodiments, the method includes a first antimetabolite delivery period during which the concentration of the antimetabolite in the urine of the individual is from 1 to 15 μg / mL; a drug withdrawal period after the first antimetabolite delivery period; and a second antimetabolite delivery period after the drug withdrawal period during which the concentration of the antimetabolite in the urine of the individual is from 1 to 15 μg / mL. In some embodiments, the method includes a first antimetabolite delivery period during which the concentration of the antimetabolite in the urine of the individual is from 3 to 10 μg / mL; a drug withdrawal period after the first antimetabolite delivery period; and a second antimetabolite delivery period after the drug withdrawal period during which the concentration of the antimetabolite in the urine of the individual is from 3 to 10 μg / mL.

[0130] The concentration of the antimetabolite in the urine of the individual can increase during at least a portion of the drug withdrawal period. For example, the concentration of the antimetabolite in the urine may be higher than about 1 μg / mL over at least a portion of the drug withdrawal period. In some embodiments, the concentration of the antimetabolite in the urine of the individual is higher than about 5 μg / mL over at least a portion of the drug withdrawal period. In some embodiments, the concentration of the antimetabolite in the urine of the individual is higher than about 7 μg / mL over at least a portion of the drug withdrawal period. In some embodiments, the concentration of the antimetabolite in the urine of the individual is higher than about 10 μg / mL over at least a portion of the drug withdrawal period. In some embodiments, the concentration of the antimetabolite is from 1 μg / mL to 10 μg / mL over at least a portion of the drug withdrawal period.

[0131] In some embodiments, the concentration of the metabolite antagonist in the urine of the individual is higher than about 1 μg / mL for at least 1 / 4 of the drug withdrawal period. In some embodiments, the concentration of the metabolite antagonist in the urine of the individual is higher than about 5 μg / mL for at least 1 / 4 of the drug withdrawal period. In some embodiments, the concentration of the metabolite antagonist in the urine of the individual is higher than about 7 μg / mL for at least 1 / 4 of the drug withdrawal period. In some embodiments, the concentration of the metabolite antagonist in the urine of the individual is higher than about 10 μg / mL for at least 1 / 4 of the drug withdrawal period. In some embodiments, the concentration of the metabolite antagonist in the urine of the individual is from 1 μg / mL to 10 μg / mL for at least 1 / 4 of the drug withdrawal period.

[0132] In some embodiments, the concentration of the metabolite antagonist in the urine of the individual is higher than about 1 μg / mL for at least 1 / 2 of the drug withdrawal period. In some embodiments, the concentration of the metabolite antagonist in the urine of the individual is higher than about 5 μg / mL for at least 1 / 2 of the drug withdrawal period. In some embodiments, the concentration of the metabolite antagonist in the urine of the individual is higher than about 7 μg / mL for at least 1 / 2 of the drug withdrawal period. In some embodiments, the concentration of the metabolite antagonist in the urine of the individual is higher than about 10 μg / mL for at least 1 / 2 of the drug withdrawal period. In some embodiments, the concentration of the metabolite antagonist in the urine of the individual is from 1 μg / mL to 10 μg / mL for at least 1 / 2 of the drug withdrawal period.

[0133] In some embodiments, the concentration of the metabolite antagonist in the urine of the individual is higher than about 1 μg / mL for at least 3 / 4 of the drug withdrawal period. In some embodiments, the concentration of the metabolite antagonist in the urine of the individual is higher than about 5 μg / mL for at least 3 / 4 of the drug withdrawal period. In some embodiments, the concentration of the metabolite antagonist in the urine of the individual is higher than about 7 μg / mL for at least 3 / 4 of the drug withdrawal period. In some embodiments, the concentration of the metabolite antagonist in the urine of the individual is higher than about 10 μg / mL for at least 3 / 4 of the drug withdrawal period. In some embodiments, the concentration of the metabolite antagonist in the urine of the individual is from 1 μg / mL to 10 μg / mL for at least 3 / 4 of the drug withdrawal period.

[0134] In some embodiments, the concentration of the antimetabolite in the urine of the individual can increase over the entire drug withdrawal period. For example, the concentration of the antimetabolite may be higher than about 1 μg / mL over the entire drug withdrawal period. In some embodiments, the concentration of the antimetabolite in the urine of the individual is higher than about 5 μg / mL over the entire drug withdrawal period. In some embodiments, the concentration of the antimetabolite in the urine of the individual is higher than about 7 μg / mL over the entire drug withdrawal period. In some embodiments, the concentration of the antimetabolite in the urine of the individual is higher than about 10 μg / mL over the entire drug withdrawal period. In some embodiments, the concentration of the antimetabolite in the urine of the individual is from 1 μg / mL to 10 μg / mL over the entire drug withdrawal period.

[0135] In some embodiments, the method includes delivering the antimetabolite to the individual at least once every three months over about one year. In some embodiments, the method includes delivering the antimetabolite to the individual at least once every three months over about two years. In some embodiments, the method includes delivering the antimetabolite to the individual at least once every three months over about three years. In some embodiments, the method includes delivering the antimetabolite to the individual at least once every six months over about one year. In some embodiments, the method includes delivering the antimetabolite to the individual at least once every six months over about two years. In some embodiments, the method includes delivering the antimetabolite to the individual at least once every six months over about three years.

[0136] The rate of release of the metabolic antagonist can be varied over the course of delivery. For example, in some embodiments, the method includes delivering the metabolic antagonist at a first release rate at a first time of delivery, followed by a second time of delivery having a second release rate. In some of these embodiments, the first release rate is faster than the second release rate. In other embodiments, the first release rate is slower than the second release rate. In some embodiments, the method includes delivering the metabolic antagonist at a first dose at a first time of delivery, followed by delivering the metabolic antagonist at a second dose at a second time of delivery. In some embodiments, the first time and the second time are continuous. In some embodiments, the first and second times are separated by a drug-free period.

[0137] The second agent can be delivered locally and / or systemically at different times of delivery. For example, in some embodiments, the second agent is delivered systemically at a first time of a second agent delivery period, followed by local delivery at a second time of the second agent delivery period. In some embodiments, the second agent is delivered locally at a first time of a second agent delivery period, followed by systemic delivery at a second time of the second agent delivery period. In some of these embodiments, the first time of the second agent delivery period and the second time of the second delivery period of the second agent delivery period are separated by at least about one month.

[0138] The metabolic antagonist and the second agent can be delivered simultaneously or sequentially. In some embodiments, the metabolic antagonist and the second agent are delivered via a single delivery device.

[0139] The metabolic antagonist and the second agent may advantageously be delivered at the same release rate to provide a synergistic effect. In other embodiments, the metabolic antagonist and the second agent can be delivered at different release rates. For example, the metabolic antagonist can be delivered at a rate slower than the rate of delivery of the second agent, or the metabolic antagonist can be delivered at a rate faster than the rate of delivery of the second agent.

[0140] In some embodiments, the method includes delivery of an antimetabolite and delivery of a second agent, such as an immunomodulatory agent. Various dosages of the immunomodulatory agent may be used depending on the particular immunomodulatory agent being used. The amount of immunomodulatory agent delivered to the individual may be based on the approved dosage of the immunomodulatory agent as a monotherapy, or may be higher or lower than the dosage of the immunomodulatory agent delivered when used as a monotherapy. For example, the immunomodulatory agent may be delivered at a dosage of about 1, about 2, about 3, about 4, about 5, about 6, about 7, about 8, about 9, about 10, about 15, or about 20 mg / kg.

[0141] In some embodiments, the immunomodulatory agent may include the anti-PD1 antibody nivolumab and may be delivered at a dosage of about 3 mg / kg. In some embodiments, nivolumab may be delivered at a dosage of 3 mg / kg every two weeks. In some embodiments, nivolumab may be delivered in combination with ipilimumab. In some of these embodiments, nivolumab may be delivered at a dosage of 1 mg / kg, followed by ipilimumab at 4 dosages every three weeks on the same day, followed by nivolumab at a dosage of 3 mg / kg every two weeks. In some embodiments, the immunomodulatory agent may include the anti-PD1 antibody pembrolizumab and may be administered at a dosage of 2 mg / kg every three weeks.

[0142] In some embodiments, the second agent may be delivered before the start of antimetabolite delivery. In some embodiments, the second agent may be delivered after the end of antimetabolite delivery. In some embodiments, the second agent may be administered during the antimetabolite delivery period. In some embodiments, the antimetabolite delivery period and the second agent delivery period overlap with each other. In some embodiments, the antimetabolite delivery period and the second agent delivery period are non-overlapping.

[0143] In some embodiments, the second agent may be delivered during a drug holiday. In some embodiments, the second agent may be delivered during the first antimetabolite delivery period or the second antimetabolite delivery period.

[0144] In some embodiments, the methods provided herein include delivering an effective amount of an antimetabolite to an individual over a period of at least about 24 hours and delivering an effective amount of a second agent. In some embodiments, the methods provided herein include delivering an effective amount of an antimetabolite to an individual over a period of at least about 48 hours and delivering an effective amount of a second agent. In some embodiments, the methods provided herein include delivering an effective amount of an antimetabolite to an individual over a period of at least about 60 hours and administering an effective amount of a second agent. In some embodiments, the methods provided herein include delivering an effective amount of an antimetabolite to an individual over a period of at least about 72 hours and delivering an effective amount of a second agent. In some embodiments, the methods provided herein include delivering an effective amount of an antimetabolite to an individual over a period of at least about 7 days and delivering an effective amount of a second agent.

[0145] In some embodiments, the methods provided herein include delivering an effective amount of an antimetabolite to an individual over a period between 24 hours and about 1 month and delivering an effective amount of a second agent to the individual. In some embodiments, the methods provided herein include delivering an effective amount of an antimetabolite to an individual over a period between about 24 hours and about 21 days and delivering an effective amount of a second agent to the individual. In some embodiments, the methods provided herein include delivering an effective amount of an antimetabolite to an individual over a period between about 24 hours and about 14 days and delivering an effective amount of a second agent to the individual. In some embodiments, the methods provided herein include delivering an effective amount of an antimetabolite to an individual over a period between about 24 hours and about 7 days and delivering an effective amount of a second agent to the individual.

[0146] In some embodiments, the methods provided herein include delivering an effective amount of an antimetabolite to an individual over a period of about 7 days and delivering an effective amount of a second agent to the individual. In some embodiments, the methods provided herein include delivering an effective amount of an antimetabolite to an individual over a period of about 3 weeks and delivering an effective amount of a second agent to the individual. In some embodiments, the methods provided herein include delivering an effective amount of an antimetabolite to an individual over a period of about 6 weeks and delivering an effective amount of a second agent to the individual.

[0147] In some embodiments, the methods provided herein include delivering an effective amount of an antimetabolite to an individual over a period between 24 hours and about 1 month and delivering an effective amount of a second agent to the individual, wherein when the second agent is delivered, the concentration of the antimetabolite in the urine of the individual is less than about 1 μg / mL. In some embodiments, the methods provided herein include delivering an effective amount of an antimetabolite to an individual over a period between about 24 hours and about 21 days and delivering an effective amount of a second agent to the individual, wherein when the second agent is delivered, the concentration of the antimetabolite in the urine of the individual is less than about 1 μg / mL. In some embodiments, the methods provided herein include delivering an effective amount of an antimetabolite to an individual over a period between about 24 hours and about 14 days and administering an effective amount of a second agent to the individual, wherein when the immunomodulatory agent is delivered, the concentration of the antimetabolite in the urine of the individual is less than about 1 μg / mL. In some embodiments, the methods provided herein include delivering an effective amount of an antimetabolite to an individual over a period between about 24 hours and about 7 days and delivering an effective amount of a second agent to the individual, wherein when the second agent is delivered, the concentration of the antimetabolite in the urine of the individual is less than about 1 μg / mL.

[0148] In some embodiments, the methods provided herein include delivering an effective amount of an antimetabolite to an individual over a period between 24 hours and about one month and administering an effective amount of a second agent to the individual, wherein when the second agent is delivered, the concentration of the antimetabolite in the urine of the individual is less than about 5 μg / mL. In some embodiments, the methods provided herein include delivering an effective amount of an antimetabolite to an individual over a period between about 24 hours and about 21 days and delivering an effective amount of a second agent to the individual, wherein when the second agent is delivered, the concentration of the antimetabolite in the urine of the individual is less than about 5 μg / mL. In some embodiments, the methods provided herein include delivering an effective amount of an antimetabolite to an individual over a period between about 24 hours and about 14 days and administering an effective amount of a second agent to the individual, wherein when the second agent is delivered, the concentration of the antimetabolite in the urine of the individual is less than about 5 μg / mL. In some embodiments, the methods provided herein include delivering an effective amount of an antimetabolite to an individual over a period between about 24 hours and about 7 days and administering an effective amount of a second agent to the individual, wherein when the second agent is delivered, the concentration of the antimetabolite in the urine of the individual is less than about 5 μg / mL.

[0149] In some embodiments, the methods provided herein include delivering an effective amount of an antimetabolite to an individual over a period between 24 hours and about 1 month and delivering an effective amount of a second agent to the individual, wherein when the second agent is delivered, the concentration of the antimetabolite in the urine of the individual is less than about 15 μg / mL. In some embodiments, the methods provided herein include delivering an effective amount of an antimetabolite to an individual over a period between about 24 hours and about 21 days and delivering an effective amount of a second agent to the individual, wherein when the second agent is delivered, the concentration of the antimetabolite in the urine of the individual is less than about 15 μg / mL. In some embodiments, the methods provided herein include delivering an effective amount of an antimetabolite to an individual over a period between about 24 hours and about 14 days and delivering an effective amount of a second agent to the individual, wherein when the second agent is delivered, the concentration of the antimetabolite in the urine of the individual is less than about 15 μg / mL. In some embodiments, the methods provided herein include delivering an effective amount of an antimetabolite to an individual over a period between about 24 hours and about 7 days and delivering an effective amount of a second agent to the individual, wherein when the second agent is delivered, the concentration of the antimetabolite in the urine of the individual is less than about 15 μg / mL.

[0150] In some embodiments, the methods provided herein include delivering an effective amount of an antimetabolite to an individual over a period between 24 hours and about one month and delivering an effective amount of a second agent to the individual, wherein when the second agent is delivered, the concentration of the antimetabolite in the urine of the individual is higher than about 1 μg / mL. In some embodiments, the methods provided herein include delivering an effective amount of an antimetabolite to an individual over a period between about 24 hours and about 21 days and delivering an effective amount of a second agent to the individual, wherein when the second agent is delivered, the concentration of the antimetabolite in the urine of the individual is higher than about 1 μg / mL. In some embodiments, the methods provided herein include delivering an effective amount of an antimetabolite to an individual over a period between about 24 hours and about 14 days and delivering an effective amount of a second agent to the individual, wherein when the second agent is delivered, the concentration of the antimetabolite in the urine of the individual is higher than about 1 μg / mL. In some embodiments, the methods provided herein include delivering an effective amount of an antimetabolite to an individual over a period between about 24 hours and about 7 days and delivering an effective amount of a second agent to the individual, wherein when the second agent is delivered, the concentration of the antimetabolite in the urine of the individual is higher than about 1 μg / mL.

[0151] In some embodiments, the methods provided herein include delivering an effective amount of an antimetabolite to an individual over a period between 24 hours and about 1 month and delivering an effective amount of a second agent to the individual, wherein when the second agent is delivered, the concentration of the antimetabolite in the urine of the individual is higher than about 5 μg / mL. In some embodiments, the methods provided herein include delivering an effective amount of an antimetabolite to an individual over a period between about 24 hours and about 21 days and delivering an effective amount of a second agent to the individual, wherein when the second agent is delivered, the concentration of the antimetabolite in the urine of the individual is higher than about 5 μg / mL. In some embodiments, the methods provided herein include delivering an effective amount of an antimetabolite to an individual over a period between about 24 hours and about 14 days and delivering an effective amount of a second agent to the individual, wherein when the second agent is delivered, the concentration of the antimetabolite in the urine of the individual is higher than about 5 μg / mL. In some embodiments, the methods provided herein include delivering an effective amount of an antimetabolite to an individual over a period between about 24 hours and about 7 days and delivering an effective amount of a second agent to the individual, wherein when the second agent is delivered, the concentration of the antimetabolite in the urine of the individual is higher than about 5 μg / mL.

[0152] In some embodiments, the methods provided herein include delivering an effective amount of an antimetabolite to an individual over a period between 24 hours and about one month and delivering an effective amount of a second agent to the individual, wherein when the second agent is delivered, the concentration of the antimetabolite in the urine of the individual is higher than about 15 μg / mL. In some embodiments, the methods provided herein include delivering an effective amount of an antimetabolite to an individual over a period between about 24 hours and about 21 days and delivering an effective amount of a second agent to the individual, wherein when the second agent is delivered, the concentration of the antimetabolite in the urine of the individual is higher than about 15 μg / mL. In some embodiments, the methods provided herein include delivering an effective amount of an antimetabolite to an individual over a period between about 24 hours and about 14 days and delivering an effective amount of a second agent to the individual, wherein when the second agent is delivered, the concentration of the antimetabolite in the urine of the individual is higher than about 15 μg / mL. In some embodiments, the methods provided herein include delivering an effective amount of an antimetabolite to an individual over a period between about 24 hours and about 7 days and delivering an effective amount of a second agent to the individual, wherein when the second agent is delivered, the concentration of the antimetabolite in the urine of the individual is higher than about 15 μg / mL.

[0153] The second agent can be delivered locally to the bladder of the individual or systemically. For example, the second agent can be delivered into the bladder cavity (intravesically) via a bladder intra-cavity device, a bladder pump, a catheter, or an injection. The second agent can also be delivered orally, parenterally, or intravenously.

[0154] In some embodiments, the second agent is delivered systemically, followed by local delivery of the antimetabolite. In some embodiments, the second agent is first delivered systemically and then locally. In some embodiments, the second agent is first administered locally and then systemically.

[0155] Metabolic antagonists include cytidine analogs, uracil analogs, purine analogs, deoxyadenosine analogs, deoxycytosine analogs, guanosine analogs, deoxyguanosine analogs, thymidine analogs, and deoxyuridine analogs. Exemplary nucleoside analogs include azacitidine, decitabine, cytarabine, gemcitabine, 5-fluorouracil, capecitabine, azathioprine, mercaptopurine, thioguanine, fludarabine, vidarabine, cytarabine, lamivudine, zalcitabine, abacavir, acyclovir, entecavir, stavudine, telbivudine, zidovudine, idoxuridine, and trifluridine.

[0156] In another aspect, the methods provided herein may include delivery of a metabolic antagonist, an immunomodulatory agent, and an additional therapeutic agent. In some embodiments, the additional agent is Bacillus Calmette-Guerin (BCG). The additional therapeutic agent may also be a checkpoint inhibitor antagonist or an immunostimulatory molecule described herein. For example, the additional therapeutic agent may be an anti-PD-1 antibody, an anti-PD-L1 antibody, or an anti-CTLA-4 antibody.

[0157] The second or additional agent may also include additional chemotherapeutic agents such as oxaliplatin, cisplatin, docetaxel, carboplatin, docetaxel, paclitaxel, anti-VEGF antibodies, antimetabolites (including nucleoside analogs), platinum-based agents, alkylating agents, tyrosine kinase inhibitors, anthracycline antibiotics, vinca alkaloids, transition metal complexes, proteasome inhibitors, macrolides, and topoisomerase inhibitors. In some embodiments, the chemotherapeutic agent is a platinum-based agent such as carboplatin, rapamycin or its derivatives, and geldanamycin or its derivatives (e.g., 17-allylaminogeldanamycin (17-AAG)), retinoids, agents that disrupt microtubule formation (e.g., colchicine and its derivatives), anti-angiogenic agents, therapeutic antibodies, and EGFR targeting agents.

[0158] In some embodiments, the methods provided herein include the step of locally administering an antimetabolite (e.g., gemcitabine) to the bladder in combination with radiation therapy or surgery. For example, antimetabolite (e.g., gemcitabine) delivery can be initiated in an adjuvant setting prior to surgery or in a neoadjuvant setting after surgery. In some embodiments, antimetabolite (e.g., gemcitabine) delivery can be initiated at the time of surgery. In some embodiments, antimetabolite (e.g., gemcitabine) delivery can be initiated before or after radiation therapy. In some embodiments, an individual undergoing treatment with an antimetabolite (e.g., gemcitabine) does not undergo radiation therapy.

[0159] In some embodiments, antimetabolite (e.g., gemcitabine) delivery can be administered during cystoscopy.

[0160] In some embodiments, the method delays the need for cystectomy. In some embodiments, the method can be used to expand the treatment area prior to cystectomy.

[0161] In some embodiments, the cancer is resected prior to administration of an antimetabolite (e.g., gemcitabine). In some embodiments, the individual undergoes TURBT prior to administration of an antimetabolite (e.g., gemcitabine) to the bladder. In some embodiments, the tumor is resected maximally prior to administration of gemcitabine such that no visible tumor remains. In some embodiments, the patient is T0 after TURBT. In some embodiments, provided herein is a method of treating muscle-invasive bladder cancer in an individual, the method comprising: a) a step of resected the tumor, and b) a step of locally administering gemcitabine to the bladder for at least 24 hours. In some embodiments, provided herein is a method of treating non-muscle-invasive bladder cancer in an individual, the method comprising: a) a step of resected the tumor, and b) a step of locally administering gemcitabine to the bladder for at least 24 hours. Patient population

[0162] The methods provided herein are useful for treating a range of individuals having urothelial cancer. For example, in some embodiments, the urothelial cancer is bladder cancer. In some embodiments, the bladder cancer is locally advanced bladder cancer. In some embodiments, the bladder cancer is metastatic bladder cancer. In some embodiments, the bladder cancer is muscle-invasive bladder cancer. In some embodiments, the bladder cancer is non-muscle-invasive bladder cancer. In some embodiments, the bladder cancer is carcinoma in situ. In some embodiments, the bladder cancer is BCG (Bacillus Calmette-Guerin) refractory cancer. In some embodiments, the bladder cancer is papillary bladder cancer. In some embodiments, the bladder cancer is grade 1 / 3, 2 / 3 or 3 / 3. In some embodiments, the bladder cancer is stage I, stage II, stage III or stage IV bladder cancer. In some embodiments, the bladder cancer is high-grade invasive papillary urothelial cancer. In some embodiments, the bladder cancer is non-invasive high-grade urothelial cancer. In some embodiments, the bladder cancer is multifocal invasive high-grade papillary urothelial cancer. In some embodiments, the bladder cancer is cT2 or cT3. In some embodiments, the bladder is carcinoma in situ and cT2.

[0163] In some embodiments, the methods provided herein include treating an individual having a compromised immune system. In some embodiments, the methods provided herein include treating an individual having a low level of checkpoint inhibitor, e.g., an individual having low expression of PD-L1 and / or PD-1. In some embodiments, the methods provided herein include treating a patient having a low, intermediate, or high level of nucleoside transporter. In some of these embodiments, the nucleoside transporter is hENT. In some embodiments, the methods provided herein include treating an individual having cytopenia. In some embodiments, the methods provided herein include treating an individual who has previously received chemotherapy. In some embodiments, the methods provided herein include treating an individual who is ineligible for immunomodulatory therapy.

[0164] In some embodiments, provided herein is a method of treating bladder cancer (e.g., MIBC) in an individual who is not eligible for neoadjuvant cisplatin-based therapy, the method comprising the step of locally administering an antimetabolite (e.g., gemcitabine) to the bladder. In some embodiments, provided herein is a method of treating bladder cancer (e.g., MIBC) in an individual who refuses neoadjuvant cisplatin-based therapy, the method comprising the step of locally administering an antimetabolite (e.g., gemcitabine) to the bladder. In some embodiments, provided herein is a method of treating bladder cancer (e.g., MIBC) in an individual having cT2 disease and no high-risk features, such as lymphovascular invasion (LVI), hydronephrosis, and concomitant carcinoma in situ (CIS), the method comprising the step of locally administering an antimetabolite (e.g., gemcitabine) to the bladder. In some embodiments, provided herein is a method of treating bladder cancer (e.g., MIBC) in an individual who is willing to undergo radical cystectomy but is ineligible for cisplatin-based neoadjuvant therapy, the method comprising the step of locally administering an antimetabolite (e.g., gemcitabine) to the bladder. In some of these embodiments, the individual has cT2 cancer. In some of the embodiments, the individual has cT2 muscle-invasive bladder cancer. In some embodiments, the antimetabolite is locally delivered to the individual's bladder for at least 24 hours. In some embodiments, the antimetabolite (e.g., gemcitabine) is locally delivered to the individual's bladder for 7 days. In some of these embodiments, 225 mg of gemcitabine is locally delivered to the bladder over 7 days. In some of these embodiments, the method comprises the step of locally delivering 225 mg of gemcitabine to the bladder over 7 days, a subsequent 14-day drug holiday, and then the step of locally delivering 225 mg of gemcitabine to the bladder over 7 days. In some embodiments, the method comprises the step of locally delivering the antimetabolite (e.g., gemcitabine) to the bladder for 3 weeks. In some embodiments, the method comprises the step of locally delivering 225 mg of gemcitabine to the bladder over 3 weeks.In some embodiments, the method comprises delivering 450 mg of gemcitabine locally to the bladder over a period of six weeks. In some embodiments, the antimetabolite is gemcitabine.

[0165] In some embodiments, the individual is ineligible for cisplatin-based therapy based on co-morbidities including poor general condition, renal dysfunction, hearing loss, peripheral neuropathy, and heart disease. In some embodiments, the individual is ineligible for cisplatin-based therapy based on the absence of one or more high-risk features, such as lymphovascular invasion (LVI), hydronephrosis, and concomitant carcinoma in situ (CIS).

[0166] To date, neoadjuvant therapy followed by radical cystectomy, or removal of the bladder, has been the standard treatment for the management of muscle-invasive bladder cancer. Individuals who are not suitable for radical cystectomy undergo palliative transurethral resection of bladder tumor (TURBT) in an attempt to limit local progression of the untreated or inadequately treated disease. Such treatment can temporarily manage local symptoms such as hematuria, pain, and urgency, but is not used with curative intent. Thus, in one aspect, the present invention provides a method of treating bladder cancer (e.g., MIBC) in individuals who are not suitable or eligible for cystectomy by locally administering an antimetabolite (e.g., gemcitabine) to the bladder.

[0167] In some embodiments, provided herein is a method for treating bladder cancer (e.g., MIBC) of the lower urinary tract in an individual who is not suitable for cystectomy, the method comprising the step of locally delivering an antimetabolite (e.g., gemcitabine) to the bladder. In some embodiments, provided herein is a method for treating bladder cancer (e.g., MIBC) in an individual who is ineligible for cystectomy, the method comprising the step of locally administering an antimetabolite (e.g., gemcitabine) to the bladder. In some embodiments, provided herein is a method for treating bladder cancer (e.g., MIBC) in a frail individual, the method comprising the step of locally delivering an antimetabolite (e.g., gemcitabine) to the bladder. In some embodiments, provided herein is a method for treating bladder cancer (e.g., MIBC) in an individual who cannot tolerate radical cystectomy, the method comprising the step of locally delivering an antimetabolite (e.g., gemcitabine) to the bladder. In some embodiments, provided herein is a method for treating bladder cancer (e.g., MIBC) in an individual without removing the individual's bladder, the method comprising the step of locally delivering an antimetabolite (e.g., gemcitabine) to the bladder. In some embodiments, provided herein is a method for treating bladder cancer (e.g., MIBC) in an individual who is not suitable or ineligible for cystectomy, the method comprising the step of locally delivering an antimetabolite (e.g., gemcitabine) to the bladder. In some embodiments, provided herein is a method for treating bladder cancer (e.g., MIBC) in an individual, wherein the bladder cancer is metastatic bladder cancer. In some embodiments, provided herein is a method for treating bladder cancer (e.g., MIBC) in an individual having a cT2-cT3 disease, the method comprising the step of locally delivering an antimetabolite (e.g., gemcitabine) to the bladder. Also provided herein is a method for treating bladder cancer (e.g., MIBC) in an individual who is not suitable or eligible for cystectomy, the method comprising: a) excising the tumor; and b) locally delivering gemcitabine to the bladder.In some embodiments, provided herein is a method of treating muscle-invasive bladder cancer in an individual who is unsuitable or ineligible for cystectomy, the method comprising: a) performing TURBT; and b) locally delivering gemcitabine to the bladder for at least 7 days. In some embodiments, provided herein is a method of treating muscle-invasive bladder cancer in an individual who is unsuitable or ineligible for cystectomy, the method comprising: a) performing TURBT; and b) locally delivering gemcitabine to the bladder for a period of from 7 to 180 days, from 7 to 90 days, from 7 to 60 days, from 7 to 30 days, from 7 to 21 days, or from 7 to 14 days. In some of these embodiments, gemcitabine can be delivered chronically or continuously to the bladder over the life of the individual to improve the quality of life of the individual. In some embodiments, an antimetabolite (e.g., gemcitabine) is locally delivered to the bladder of the individual for at least 24 hours. In some embodiments, an antimetabolite (e.g., gemcitabine) is locally delivered to the bladder of the individual for a period of from 24 hours to 3 weeks, from 2 to 20 days, from 3 to 16 days, or from 4 to 14 days. In some embodiments, an antimetabolite (e.g., gemcitabine) is locally delivered to the bladder of the individual for 7 days. In some of these embodiments, 225 mg of gemcitabine is locally delivered to the bladder over a 7-day period. In some of these embodiments, the method comprises locally delivering 225 mg of gemcitabine to the bladder for 7 days, followed by a 14-day drug holiday, followed by locally delivering 225 mg of gemcitabine to the bladder for 7 days. In some embodiments, the method comprises locally delivering an antimetabolite to the bladder for 3 weeks. In some embodiments, the method comprises locally delivering 225 mg of gemcitabine to the bladder over a 3-week period. In some embodiments, the method comprises locally delivering 450 mg of gemcitabine to the bladder over a 6-week period. In some embodiments, the antimetabolite is gemcitabine.

[0168] In some embodiments, the individual is ineligible for radical cystectomy under the National Comprehensive Cancer Network (NCCN) guidelines. For example, the individual may be unfit for curative treatment due to frailty. Prior to the present method, such individuals typically received palliative radiation without chemotherapy (3.5 Gy / fraction - 10 treatments; or 7 Gy / fraction - 7 treatments; TURBT; or no treatment). In some embodiments, the individual is unsuitable for platinum-based chemotherapy. In some embodiments, chemotherapy prior to radiation therapy is not recommended for the individual. In some embodiments, the individual receives neither curative treatment nor systemic chemotherapy. In some embodiments, the individual has cT2-cT3 disease.

[0169] In some embodiments, the individual is unable to tolerate radical cystectomy based on the American Society of Anesthesiology (ASA) guidelines. For example, an individual unable to tolerate radical cystectomy may be considered medically unfit for surgeries that require general or epidural anesthesia.

[0170] In other embodiments, the individual may lack the infrastructure or personnel for effective postoperative care as determined by a Comprehensive Geriatric Assessment provided by the American Society of Anesthesiologists. Under these guidelines, an individual is considered frail if they exhibit abnormalities in independent activities of daily living, severe malnutrition, cognitive impairment, or comorbidities with a geriatric cumulative illness rating scale (CISR-G) grade of 3-4.

[0171] The method of the present invention also provides important and significant treatment benefits as compared to standard treatment regimens that require removal of the bladder. The present invention also has the advantage of being useful as a bladder preservation protocol for individuals who are eligible for but choose not to undergo cystectomy. The method of the present invention results in a significantly improved quality of life for individuals who may be able to retain their bladders after having bladder cancer as compared to currently available treatments. Thus, in some embodiments, provided herein is a method of treating bladder cancer (e.g., MIBC) in an individual, the method comprising the step of locally delivering an antimetabolite (e.g., gemcitabine) to the bladder. In some embodiments, provided herein is a method of treating bladder cancer (e.g., MIBC) without removing the individual's bladder, the method comprising the step of locally delivering an antimetabolite (e.g., gemcitabine) to the bladder. Also provided herein is a method of treating bladder cancer (e.g., MIBC) in an individual who would otherwise undergo cystectomy, the method comprising the step of locally delivering an antimetabolite (e.g., gemcitabine) to the bladder. In some embodiments, provided herein is a method of treating bladder cancer (e.g., MIBC) in an individual who is eligible for but chooses not to undergo cystectomy, the method comprising the step of locally delivering an antimetabolite (e.g., gemcitabine) to the bladder. In some embodiments, provided herein is a method of bladder preservation as an alternative to radical cystectomy, the method comprising the step of locally delivering an antimetabolite (e.g., gemcitabine) to the bladder. In some embodiments, provided herein is a method of treating bladder cancer (e.g., MIBC) in an individual who chooses not to undergo cystectomy, the method comprising the step of locally delivering an antimetabolite (e.g., gemcitabine) to the bladder. In some embodiments, provided herein is a method of preserving an individual's bladder, the method comprising the step of locally delivering an antimetabolite (e.g., gemcitabine) to the bladder.In some embodiments, provided herein is a method of treating bladder cancer (e.g., MIBC) in an individual without removing the bladder, the method comprising the step of locally delivering an antimetabolite (e.g., gemcitabine) to the bladder. In some embodiments, provided herein is a method of treating CT2 urothelial cancer in an individual who would otherwise undergo cystectomy, the method comprising the step of locally delivering an antimetabolite (e.g., gemcitabine) to the individual's bladder. In some embodiments, the antimetabolite (e.g., gemcitabine) is locally delivered to the individual's bladder for at least 24 hours. In some embodiments, the antimetabolite (e.g., gemcitabine) is locally delivered to the individual's bladder for a period of 24 hours to 3 weeks, 2 to 20 days, 3 to 16 days, or 4 to 14 days. In some embodiments, the antimetabolite (e.g., gemcitabine) is locally delivered to the individual's bladder for 7 days. In some of these embodiments, 225 mg of gemcitabine is locally delivered to the bladder over 7 days. In some of these embodiments, the method comprises the step of locally delivering 225 mg of gemcitabine to the bladder over 7 days, a subsequent 14-day drug-free period, and then the step of locally delivering 225 mg of gemcitabine to the bladder over 7 days. In some embodiments, the method comprises the step of locally delivering an antimetabolite (e.g., gemcitabine) to the bladder for a period of 3 weeks. In some embodiments, the method comprises the step of locally delivering 225 mg of gemcitabine to the bladder over 3 weeks. In some embodiments, the method comprises the step of locally delivering 450 mg of gemcitabine to the bladder over a period of 6 weeks. In some embodiments, the antimetabolite is gemcitabine.

[0172] In some embodiments, the method is particularly suitable for the treatment of individuals having CT2 patients who typically undergo radical resection and subsequent neoadjuvant therapy. The method results in local / regional control of the disease, including the lymph nodes, and can thus be used for long-term treatment in this bladder-sparing population. The method also results in the absence of invasive recurrence, good long-term bladder function, and a low rate of salvage cystectomy, all of which are primarily important in a relatively frail population of elderly individuals with bladder cancer, having an average age of 70 years. Endpoint

[0173] The methods provided herein are useful for the treatment of urothelial cancer of the lower urinary tract. In some embodiments, the methods provided herein result in a decrease in time to metastasis. In some embodiments, the methods provided herein prevent metastasis. In some embodiments, the methods provided herein result in the prevention of lymph node metastasis. In some embodiments, the methods provided herein prevent nodal involvement. In some embodiments, the methods provided herein increase the pathologic response rate as compared to existing treatments. For example, the methods provided herein achieve a pathologic response rate of about 20%, about 30%, about 40%, about 50%, about 60%, about 70%, about 80%, about 90% or about 100%. In some embodiments, the methods provided herein result in individuals that are not upstaged at the time of cystectomy. In some embodiments, the methods provided herein result in a decrease in tumor size, or pathologic or clinical downstaging of the tumor. In some embodiments, the methods provided herein result in increased clinical complete response (cCR), partial response (cPR) and / or overall response (cOR) as compared to standard of care as of March 2017. In some embodiments, the methods provided herein result in pathologic complete response (pCR) or pathologic partial response (pPR). In some embodiments, pPR is defined as the absence of residual invasive cancer and the presence of residual non-muscle invasive cancer. In some embodiments, pCR is defined as the absence of residual cancer in the bladder and the regional lymph nodes. In some embodiments, the methods result in an improvement in disease-free survival or overall survival. In some embodiments, the methods result in a decrease in hematuria.

[0174] In some embodiments, the methods provided herein result in the disappearance of muscle-invasive tumors. In some embodiments, the methods provided herein result in the complete disappearance of muscle-invasive tumors such that the pathological histological stage is pT0 upon treatment. In some embodiments, the methods provided herein result in the disappearance of muscle-invasive tumors with residual pTis. In some embodiments, the methods provided herein do not result in residual exophytic tumors. In some embodiments, the methods provided herein result in a significant reduction in tumor volume. In some embodiments, the methods provided herein result in tumor shrinkage. II. Intravesical (within the bladder) device Device shape

[0175] In some embodiments, the methods provided herein include administering an antimetabolite (such as gemcitabine) using an intravesical (within the bladder) device. In some embodiments, the intravesical (within the bladder) device includes a deployment shape and a retention shape. For example, the device may be elastically deformable between a relatively straight, i.e., uncoiled, shape (deployment shape) suitable for insertion into an individual's bladder through a lumen (such as the urethra) and a retention shape suitable for retaining the device within the bladder. For the purposes of this disclosure, terms such as "relatively expanded shape," "relatively high profile shape," or "retention shape" generally refer to any shape suitable for retaining the device at the intended implantation site, including but not limited to a pretzel shape or other coil shape (such as including a bi-oval or overlapping coils) suitable for retaining the device within the bladder. The retention shape is such that the device is not drawn into and excreted in the urine when the individual urinates. Similarly, terms such as "relatively low profile shape" or "deployment shape" generally refer to any shape suitable for deploying a drug delivery device to the body, such as the bladder, including but not limited to a linear or elongated shape suitable for deploying the device through the working channel of a catheter, cystoscope, or other deployment device placed in the urethra. In embodiments, the drug delivery device can naturally assume a relatively expanded shape and be deformed manually or using an external device to a relatively low profile shape for insertion into the body. For example, the external device may be an inserter configured for transurethral insertion. The intravesical (within the bladder) device returns to its initially relatively expanded shape for retention in the body spontaneously or naturally upon deployment. In some embodiments, the device behaves in a spring-like manner and deforms in response to a compressive load (e.g., the device deforms to the deployment shape), but returns spontaneously to the retention shape when the load is removed.

[0176] In some embodiments, the shape-changing functionality of the intravesical (within the bladder) device described in the previous paragraph may be provided by including within the device a shape-retaining frame (i.e., a “retaining frame”), such as that disclosed in the patent application publications incorporated herein by reference. In some embodiments, the device may include a retaining frame lumen in which a retaining frame, which may be an elastic wire, such as a superelastic alloy like nitinol, is secured. The retaining frame may be configured to spontaneously return to a retaining shape, such as a “pretzel” shape or another coiled shape, like that disclosed in the previously incorporated applications. In particular, the retaining frame can hold the device within the body, such as within the bladder. The retaining shape is such that when the individual urinates, the device is not drawn into the urine and excreted. For example, the retaining frame enables the device to be introduced into the body in a relatively low-profile shape, allows the device to return to a relatively expanded shape within the body, and has an elastic limit and modulus of elasticity that prevent the device from assuming a relatively low-profile shape within the body in response to expected forces, such as the contraction of the detrusor muscle and the fluid forces associated with urination. Thereby, the device can limit or prevent accidental expulsion when deployed and can be retained within the individual's bladder.

[0177] In some other embodiments, the shape-changing functionality of the intravesical (within the bladder) device may be provided by forming the device housing at least partially from a thermally shape set elastic polymer.

[0178] The material used to form the device body (i.e., the housing) may be at least partially elastic or flexible so that the device can move between the deployment and retention shapes. When the device is in the retention shape, the retention frame portion may tend to be placed within the drug reservoir portion as shown, although in other cases the retention frame portion may be located inside, outside, above or below the drug reservoir portion. The material used to form the device body may be water permeable, such that a solubilizing fluid (e.g., urine) can enter the drug reservoir portion to solubilize the non-liquid form of an antimetabolite, immunomodulatory agent, additional therapeutic agent, functional agent or combination thereof contained in the drug reservoir when the device is deployed in the bladder. For example, silicone or another biocompatible elastomeric material may be used. In other embodiments, the device body may be formed, at least in part, of a water impermeable material.

[0179] In some embodiments, the device body is made of an elastic, biocompatible polymer material. The material may be non-absorbable or absorbable. Examples of non-absorbable materials include synthetic polymers selected from poly(ether), poly(acrylate), poly(methacrylate), poly(vinyl pyrrolidones), poly(vinyl acetate), poly(urethane), cellulose, cellulose acetate, poly(siloxane), poly(ethylene), poly(tetrafluoroethylene) and other fluorinated polymers, and poly(siloxane). Examples of absorbable materials, specifically biodegradable or bioerodible polymers, include synthetic polymers selected from poly(amide), poly(ester), poly(ester amide), poly(anhydride), poly(orthoester), polyphosphazene, pseudo poly(amino acid), poly(glycerol-sebacic acid), poly(lactic acid), poly(glycolic acid), poly(lactic-co-glycolic acid), poly(caprolactone), poly(caprolactone) (PC) derivatives, amino alcohol-based poly(ester amide) (PEA) and poly(octane-diol citrate) (POC) and other curable bioabsorbable elastomers. PC-based polymers may require additional crosslinking agents such as lysine diisocyanate or 2,2-bis(e-caprolactone-4-yl) propane to obtain elastomeric properties. Copolymers, mixtures and combinations of the above materials may also be used.

[0180] In some embodiments, the device body comprises silicone, thermoplastic polyurethane, ethyl vinyl acetate (EVA), or a combination thereof. In some embodiments, the device body comprises two different thermoplastic materials, one of which is a hydrophilic thermoplastic polyurethane that is drug permeable and the other is drug impermeable. The drug impermeable material may be selected from the group consisting of hydrophilic polyurethanes, hydrophilic polyesters and hydrophilic polyamides. The device body may include an annular tube formed by an extrusion or coextrusion process as described in U.S. Patent Publication No. 2016 / 0310715 using one or more of these materials. Drug core

[0181] In embodiments where an antimetabolite is delivered from a bladder (intravesical) drug delivery device, the drug may be contained in the device in various forms, depending on the particular mechanism by which the device controllably releases the drug into the fluid (e.g., urine) in the bladder. In some embodiments, the drug is advantageously provided in a solid, semi-solid or other non-liquid form that can facilitate stable storage of the drug prior to use of the device and advantageously allows the drug payload of the device to be stored in a smaller volume than would be possible if the drug were contained in the form of a liquid solution. In one embodiment, the non-liquid form is selected from tablets, granules, powders, semi-solids (e.g., ointments, creams, pastes or gels), capsules and combinations thereof. In one embodiment, the drug is in the form of a plurality of tablets, such as the minitablets described in U.S. Patent No. 8,343,516.

[0182] For example, the antimetabolite may take the form of a suspension, solution or emulsion in an oily or aqueous vehicle and may contain formulation agents such as suspending agents, stabilizers and / or dispersing agents. Alternatively, the active ingredient may be in powder form obtained by aseptic isolation of a sterile solid or by lyophilization from a solution for constitution with a suitable vehicle, such as sterile, pyrogen-free water, prior to use.

[0183] In one embodiment, the antimetabolite is formulated using one or more excipients that include a viscosity enhancer for the sustained release of the solubilized antimetabolite from the release aperture of the device housing. In another embodiment, the device reservoir contains both the antimetabolite and the viscosity enhancer, but they are not co-formulated and are instead provided in separate regions within the reservoir, for example as separate tablets. Suitable viscosity enhancers, including but not limited to polyethylene oxide (PEO), are known in the pharmaceutical art. In some variations of the embodiments, the viscosity enhancer may be provided and / or formulated with urea or another osmotic agent.

[0184] In one embodiment, the antimetabolite is administered to an individual together with a solubility enhancer. In one embodiment, the solubility enhancer is urea. In one embodiment, the urea is provided in tablet or other solid form and loaded together with the antimetabolite into the drug reservoir of an intravesical (within the bladder) drug delivery device. The urea may also function as an osmotic agent that promotes the generation of osmotic pressure within the drug reservoir, depending on the device. In certain embodiments, the antimetabolite and the osmotic agent are configured as separate tablets (or other solid forms) located in different regions of the drug reservoir, as described in PCT WO2015 / 026813 (Lee et al.), which is incorporated herein by reference.

[0185] In some embodiments, the device may include a drug reservoir lumen. In some of these embodiments, each drug reservoir lumen may hold one or several drug tablets, or other solid drug units. In one embodiment, the device holds about 10 to 100 cylindrical drug tablets, such as mini-tablets, in several separate drug reservoir lumens. In certain embodiments, the mini-tablets can each have a diameter of about 1.0 to about 3.3 mm, such as about 1.5 to about 3.1 mm, and a length of about 1.5 to about 4.7 mm, such as about 2.0 to about 4.5 mm. Drug housing

[0186] The release of antimetabolites from the intravesical (within the bladder) devices described herein may be driven and controlled by different mechanisms of action. In various embodiments, the drug may be released from the intravesical (within the bladder) drug delivery device by diffusion through the wall of the drug housing, by diffusion through one or more defined apertures in the wall of the drug housing, by osmotic pressure through an aperture of the drug housing, by osmotic pressure through one or more transiently formed microchannels, by erosion of the drug formulation upon contact with urine within the bladder, or by a combination thereof. In some embodiments, drug release is controlled by drug diffusion through a drug-permeable polymer or matrix component that defines a portion of the device housing. In one embodiment, the device includes a drug-permeable polymer component.

[0187] The size of the housing, including the wall thickness, may be selected based in particular on the volume of the drug (and functional agent, if any) formulation(s) contained, the desired rate of drug delivery from the device body / housing, the intended site of device implantation within the body, the desired mechanical integrity of the device, the desired release rate or permeability to water and urine, the desired induction time before the onset of initial release, and the desired method or route of insertion into the body. In embodiments where the housing is a tube, a tube wall that is too thin may not have sufficient mechanical integrity, while a tube wall that is too thick may result in an undesirably long induction time for the initial drug release from the device and / or may not have sufficient flexibility to allow delivery through the urethra or other narrow body lumens. Thus, the tube wall thickness may be determined based on the mechanical properties and water permeability of the tube material.

[0188] In some embodiments, the housing may be an elongated annular tube having an inner diameter of about 2 mm to about 5 mm. The drug, and in some cases, the functional agent, may be a solid tablet having a diameter substantially the same as the inner diameter of the elongated annular tube. In some embodiments, the housing holds one or more first drug units containing the drug, and one or more second drug units containing a functional agent that facilitates drug release. One or more of the first unit tablets may be filled in a length of about 1 cm to about 3 cm of the lumen of the tube, and one or more of the second unit tablets may be filled in a length of about 10 cm to about 15 cm of the lumen of the tube. In one embodiment, the ratio of the volume of the first unit(s) to the volume of the second unit(s) is from about 0.05 to about 0.5. Other lengths and ratios of the tablet payload are also contemplated.

[0189] In some embodiments, the housing may be an elongated annular tube having a wall thickness of 0.1 to 0.4 mm, such as 0.2 mm. The housing material may include one or more biocompatible elastomers. The housing material may be selected such that the housing has a durometer of 25A to 80A, such as 25A, 50A, 65A, 70A, or 80A.

[0190] In various embodiments, the intravesical (within the bladder) device can release the drug continuously or intermittently to achieve a drug concentration in the bladder such that a therapeutically effective concentration of the drug in the urine in the bladder is maintained as described in the methods provided herein. For example, over a period of 1 hour to 1 month, such as 2 hours to 2 weeks, 6 hours to 1 week, 24 hours to 72 hours, etc. In certain embodiments, the intravesical (within the bladder) device can release an antimetabolite in an amount of 1 mg / day to 1000 mg / day, such as 20 mg / day to 300 mg / day or 25 mg / day to 300 mg / day. In certain embodiments, these release rates are provided over the treatment period described herein. In certain embodiments, these release rates are provided over a treatment period of 14 days to 21 days. Osmosis and diffusion system

[0191] Following in vivo deployment, the device releases the drug. As described above, release can occur by an osmotic pressure gradient between the inside and outside of the device, with the drug passing through one or more apertures or passage pores in the device under osmotic pressure. Release can also occur by diffusion, whereby the drug passes through one or more apertures or passage pores in the device and / or through the drug-permeable walls of the device due to a drug concentration gradient between the inside and outside of the device. Combinations of these release modes within a single device are possible and, in some embodiments, are preferred to achieve an overall drug release profile that cannot be easily achieved by any of the individual modes.

[0192] In some embodiments where the device contains the drug in solid form, elution of the drug from the device occurs following dissolution of the drug within the device. Body fluid enters the device, contacts the drug, solubilizes the drug, and then the dissolved drug diffuses from the device or flows from the device under osmotic pressure or via diffusion. For example, the drug may be solubilized upon contact with urine if the device is deployed in the bladder. In certain embodiments, the water-permeable wall portion of the housing is permeable to the drug in aqueous solution such that the solubilized drug is released through the wall portion, also referred to herein as "trans-wall diffusion." After the device is implanted, water or urine permeates through the wall and enters the reservoir, solubilizing the functional agent and / or drug. The drug then diffuses directly through the wall at a controlled rate due to a drug concentration gradient between the inside and outside of the device. For example, the housing and / or any water or drug-permeable wall portion may be silicone, thermoplastic polyurethane, ethylene-co-vinyl acetate (EVA), or combinations thereof.

[0193] In some embodiments, the intravesical (within the bladder) device can contain a unit concentration of 225 mg of gemcitabine. In some of these embodiments, the device may be configured to deliver to the individual from about 100 to about 225 mg of gemcitabine (e.g., about 140 mg, about 160 mg, about 180 mg, about 200 mg, or about 220 mg) of antimetabolite mg over 7 days or over 3 weeks.

[0194] In certain embodiments, the drug delivery device may include a permeation system as described in both WO2014 / 145638 and U.S. Patent Publication No. 2016 / 0310715, which are hereby incorporated by reference in their entirety. In some embodiments, the drug delivery device includes a housing having a closed drug reservoir lumen bounded by a first wall structure and a hydrophilic second wall structure; and a drug formulation containing an antimetabolite contained within the drug reservoir lumen, wherein the first wall structure is permeable or impermeable to water and impermeable to the drug, and the second wall structure is permeable to the antimetabolite.

[0195] In some embodiments, the device housing serves as a boundary of a drug reservoir of a device made from a first material that serves as a first wall structure and a second material that serves as a second wall structure, thereby defining the drug reservoir, and drug release occurs basically only through the second material. In one embodiment, the device does not include an aperture; drug release is only by diffusion through the second wall structure. As used herein, the terms "impermeable to drugs" and "impermeable to water" refer to a wall structure that is substantially impermeable to drugs or water, such that drugs or water are not substantially released through the wall structure over the course of the therapeutic release period. For use in the bladder, it is desirable for the device to accommodate during detrusor contractions (i.e., be bendable easily, have a soft feel) to avoid or alleviate discomfort and irritation to the patient. Accordingly, the durometers of the first and second materials of the construct are a design consideration, and the proportion of high durometer materials may be limited in constructing a device housing of a given size while maintaining adequate compliance in the bladder. For example, a silicone tube may have a Shore hardness of 50A - 70A, while Tecophilic™ thermoplastic polyurethane (Lubrizol Corp.) may have a Shore hardness greater than 70A, such as 80A - 65D. Thus, it may be advantageous to utilize a combination of these two different polymeric materials rather than fabricating the entire device from a water-swellable, hydrophilic, drug-permeable second material.

[0196] The arrangements of the first and second wall structures may take various forms. In certain embodiments, the first wall structure is a cylindrical tube and the second wall structure is an end wall disposed at at least one end of the cylindrical tube, or the first wall structure and the second wall structure are adjacent to each other and together form a cylindrical tube. That is, drug release is controlled by drug diffusion through a drug-permeable component that defines a portion of the closed device housing. The drug-permeable wall structure may be positioned, sized, and have material properties to provide a desired rate of controlled drug diffusion from the device. In one embodiment, the drug-permeable wall may include a stabilized disk in the lumen of the tube at or near the end of the tube, optionally sandwiched between an inner washer and an outer washer. In another embodiment, the drug-permeable wall is part of a sidewall of a tubular housing or part of an end plug positioned at the end of the tubular housing.

[0197] The length and width, e.g., the wall portion formed of a water-permeable material, are selected to provide a desired rate of water flow to a reservoir defined by the device housing. In one embodiment, the width of the water-permeable wall portion is quantified by the angle of the arc that defines the wall when viewed in a cross-section perpendicular to the lumen axis. The water-permeable region(s) of the device housing may be further controlled to advantageously maintain the suitable overall dimensions and elasticity of the device formed of a more suitable biocompatible elastomer, resulting in a selected area, and thus rate, of leaching of the permeating water. Advantageously, by forming the device housing by a coextrusion process, the structural diversity of the water-permeable region(s) can be created using conventional coextrusion equipment by selection of processing parameters, thereby beneficially providing the ability to cost-effectively manufacture device configurations of multiple structures. In some embodiments, the length of the water-permeable region(s) extends over only a portion of the total length of the device. In such embodiments, a larger arc angle of the water-permeable region(s) can thus be used while maintaining the rate of drug release at a desired level over a long period of time.

[0198] In some embodiments, the wall may have varying thicknesses across the outer perimeter of the wall. For example, the drug-permeable portion may have a thickness that is thinner than the thickness of the drug-impermeable portion. Further, the thinner drug-permeable wall structure may be disposed at various positions relative to the adjacent, thicker drug-impermeable wall structure. In some embodiments, drug release is controlled by drug diffusion through a drug-permeable component that defines a portion of the closed device housing. The drug-permeable wall structure may be positioned, sized, and have material properties to provide a desired rate of controlled drug diffusion from the device.

[0199] In some embodiments, a drug delivery device includes a housing comprising a first wall structure and a second wall structure that are adjacent to each other and together form a tube that defines a drug reservoir lumen; and a drug contained within the drug reservoir lumen, wherein (i) the second wall structure, or both the first wall structure and the second wall structure, are permeable to water, (ii) the first wall structure is impermeable to the drug and the second wall structure is permeable to the drug such that the drug is releasable in vivo by diffusion through the second wall structure, (iii) the second wall structure occupies less than 90 percent of the cross-sectional area of the tube in a cross-section perpendicular to the long axis of the tube, and (iv) the first wall structure comprises a first polyurethane composition.

[0200] In some embodiments, a device includes an elongated elastic housing having a drug reservoir lumen extending between a first closed end and a second closed end; and a drug contained within the drug reservoir lumen, wherein (i) the housing includes a tubular wall structure comprising a first annular segment entirely formed of a first material that is impermeable to the drug and a second annular segment at least partially formed of a second material that is permeable to the drug and configured to release the drug in vivo by diffusion through the second material in the second annular segment, and (ii) the first annular segment is integrally formed and has a first end connected to a first end of the second annular segment.

[0201] In some embodiments, the wall defining the drug reservoir lumen may have varying thicknesses. A housing having walls of different thicknesses can improve the flexibility, compressibility, or both of the housing. Different wall thicknesses may also serve to secure the solid drug units within the drug reservoir lumen.

[0202] In some embodiments, the bladder lumen (intravesical) device body, or housing, may include an opening (e.g., at the opposite end of an annular tube) that requires sealing following loading of the drug payload into the drug reservoir during an assembly process. Any of these defined openings or ends of the housing, including an integral housing and modular housing units, may be sealed, if desired, to close the opening. This sealing may be accomplished using a sealing substance or structure. The sealing structure may be formed from a biocompatible material including, in particular, metals such as stainless steel, polymers such as silicone, ceramics or sapphire or adhesives or combinations thereof. The sealing substance or structure may be biodegradable or bioresorbable. In one embodiment, a medical grade silicone adhesive or other adhesive is loaded into the opening in liquid or effective form and then cured therein to seal the housing opening. In some embodiments, the housing includes one or more pre-defined apertures for drug release from the device. These drug release apertures are not the defined openings that are sealed. In other embodiments, the housing does not include pre-defined drug release apertures.

[0203] In some embodiments, the device releases drug without using a pre-defined drug release aperture (i.e., opening). Release of drug from a device that does not use a pre-defined drug release aperture may be driven by diffusion or osmotic pressure. Examples of such suitable “non-aperture” release systems are described in PCT Patent Application Publication No. WO2014 / 144066 (TB130) and U.S. Patent Application Publication No. 2014 / 0276636 (TB134), which are incorporated herein by reference.

[0204] In certain embodiments, the drug delivery device may include an osmotic system as described in U.S. Patent Publication No. 2016 / 0199544, U.S. Patent No. 8,679,094, and U.S. Patent Publication No. 2016 / 0008271, which are incorporated herein by reference.

[0205] In some embodiments, the device includes a housing that defines a reservoir; a first unit contained within the reservoir that contains a drug; and a second unit contained within the reservoir at a location separate from the first unit that includes a functional agent that promotes in vivo release of the drug from the housing. In some embodiments, the first unit includes one or more solid tablets that include at least one drug (e.g., an antimetabolite such as gemcitabine), and the second unit includes one or more solid tablets (e.g., including an osmotic agent such as urea). In some embodiments, the housing is in the form of an elongated elastomeric tube having a lumen (i.e., the reservoir) in which all of the solid tablets of the first and second units are aligned and contained. The diameter of the solid tablets may be substantially the same as the diameter of the lumen.

[0206] When osmotic release is the desired drug release mode, the functional agent in the second unit may include an osmotic agent that promotes osmotic release of the drug. For example, the osmotic agent may have a higher solubility than the drug such that the osmotic agent solubilizes and / or promotes subsequent release of the drug. This advantageously enables delivery of low solubility or other drugs that are typically delivered only via diffusion from devices based on osmotic delivery. The device may exhibit an induction period in which a sufficient volume of the functional agent and / or drug is solubilized to achieve an osmotic pressure gradient.

[0207] Next, the device may exhibit a reduced, non-zero order release rate over a decay period following a long period of zero order release rate. The desired delivery rate can be achieved by controlling / selecting various parameters of the device including, but not limited to, the surface area and thickness of the water-permeable wall; the permeability of the material used to form the wall to water; the shape, size, number and arrangement of the apertures; and the dissolution profiles of the drug and functional agents.

[0208] The devices described herein may be configured to release the drug, alone or in combination with osmotic release, via diffusion. The device may be configured such that the solubilized drug can pass through a portion of the housing or one or more of its apertures.

[0209] Alternatively, or in combination with the water-permeable wall portion, the housing may include at least one aperture configured to allow liquid to enter the reservoir in vivo. The housing may also include one or more apertures or passage pores configured such that the solubilized drug can pass through it.

[0210] In some embodiments of the osmotic system, the device housing includes a first elastomeric material that is water-permeable and a second elastomeric material that is water-impermeable, both materials being selected to be impermeable to the drug contained in the housing.

[0211] Figures 8A - 8C illustrate one embodiment of an intravesical device useful in the methods described herein. Device 100 includes a drug reservoir portion 102 and a retention frame portion 104. In Figure 8A, device 100 is shown in a relatively expanded shape suitable for retention within an individual's bladder. In Figure 8C, device 100 is shown in a relatively low - profile shape for deployment through working channel 202 of a deployment device 200, such as a cystoscope or other catheter, for insertion into and through a patient's urethra and into the bladder. Following deployment into the bladder (release of the device), device 100 can assume a relatively expanded shape for holding a drug delivery device within the bladder. In the illustrated embodiment, the drug reservoir and retention frame portions 102, 104 of drug delivery device 100 are axially aligned and either integrally formed or otherwise connected to each other over their lengths.

[0212] Drug delivery device 100 includes an elastic or flexible device body 106 that defines a drug reservoir lumen 108 and a retention frame lumen 110. Drug reservoir lumen 108 is configured to contain a drug (e.g., an antimetabolite) in the form of a plurality of solid drug units 112 so as to form drug reservoir portion 102. Gaps 116 or slits formed between adjacent drug units 112 allow the drug tablets 112 to move relative to each other, whereby device 100 is flexible despite the drug being loaded in solid form. Retention frame lumen 110 is configured to contain a retention frame 114 so as to form retention frame portion 104.

[0213] As shown in the cross-sectional view of FIG. 8B, the device body 106 includes a tube or wall 122 that defines a drug reservoir lumen 108 and a tube or wall 124 that defines a retention frame lumen 110. The tubes 122, 124 and lumens 108, 110 are substantially cylindrical, and the drug reservoir lumen 108 may have a relatively larger diameter than the retention frame lumen 110, although other configurations may be selected based on deployment considerations such as the amount of drug to be delivered, the diameter of the retention frame, and the inner diameter of the deployment device. The device body 106 may be integrally formed via molding or extrusion, etc., although separate construction and assembly of the tubes 122, 124 is possible. The wall 124 that defines the retention frame lumen 110 may extend along the entire length of the wall 122 that defines the drug reservoir lumen 108, such that, as shown, the retention frame lumen 110 has the same length as the drug reservoir lumen 108, although in other embodiments one wall may be shorter than the other. Further, intermittent adhesion may be used, although in the illustrated embodiment the two walls 122, 124 are adhered along the entire length of the device.

[0214] As shown in FIG. 8A, the drug reservoir lumen 108 has several drug units 112 loaded in a series arrangement. For example, between about 10 and about 100 drug units 112, such as between about 20 and about 80 drug units 112, may be loaded. The drug units may be, for example, tablets, beads or capsules. Essentially any number of drug units may be used depending on the size of the reservoir and drug units. The drug reservoir lumen 108 includes open ends 130 and 132 shown as relatively circular openings at opposite ends of the drug reservoir lumen 108. At least one of the openings provides for the insertion of drug units 112 into the drug reservoir lumen 108 during loading and assembly of the device.

[0215] The end plug 120 closes the openings 130 and 132 after the drug unit 112 is loaded. The end plug 120 may be cylindrical and may be fixed to the drug reservoir lumen 108 by frictional contact and / or an adhesive or other fixing means. Each end plug 120 includes an aperture 118 to provide a passage for releasing the drug from the drug reservoir lumen 108, as illustrated. In some alternative embodiments, only one of the end plugs includes an aperture. In some other alternative embodiments, none of the end plugs includes an aperture, and in some of these embodiments, the tube wall 122 includes a defined aperture for release of the drug therethrough.

[0216] The retention frame lumen 110 is loaded with a retention frame 114 which may be an elastic wire such as a nitinol wire that is (thermally) shaped to the overlapping coil shape shown in FIG. 8A. The retention frame 114 enables the device 100 to be introduced into the body in a relatively low profile shape, allows the device 100 to return to a relatively expanded shape within the body, and has an elastic limit and modulus of elasticity that prevent the device from assuming a relatively low profile shape within the body in response to expected forces such as the contraction of the urinary muscles and the fluid forces associated with urination. Erosion-based system

[0217] In some embodiments, which may use tablets containing low solubility drugs, the drug is provided in tablet form exposed on the tablet surface and fixed to the device, such that, as described in U.S. Patent No. 9,107,816, drug release from the device occurs by controlled erosion / dissolution. In some embodiments, the device may include a modular housing. The modular housing is typically formed from at least two separate housing units, each unit containing at least one solid drug unit. The material forming each housing unit defines at least one drug reservoir lumen capable of containing the solid drug unit. The drug reservoir lumen may have one or more defined openings. For example, the drug reservoir lumen may have two opposing openings that expose the corresponding opposite end surfaces of at least one solid drug unit contained therein. In certain embodiments, at least two separate housing units in the modular housing are directly or indirectly connected by a retaining frame. In some embodiments, the modular housing units may be placed on the retaining frame to form a "bracelet" design. The device may have one housing unit or multiple housing units. The number of housing units may be limited only by the size of the retaining frame to which they are connected.

[0218] In some embodiments, one or more of the separate housing units include a retention frame lumen through which a shared retention frame extends. In certain embodiments, the retention frame lumen and the drug reservoir lumen of each housing unit are arranged parallel to each other. In specific embodiments, the retention frame lumen and the drug reservoir lumen of each housing unit are arranged perpendicular to each other. In further embodiments, the retention frame lumen and the drug reservoir lumen of each housing unit are arranged at an angle other than 0° (parallel) and 90° (perpendicular), such as 5, 10, 30, 45, 60 or 85°. In further embodiments, the devices described herein have the following three-dimensional configurations: (1) the retention frame lumen and the drug reservoir lumen are arranged substantially parallel to each other, (2) the retention frame lumen and the drug reservoir lumen are arranged substantially perpendicular to each other, and (3) the retention frame lumen and the drug reservoir lumen are arranged at an angle other than 0° (parallel) and 90° (perpendicular), and include two or more housing units including at least two of them. Integrated silicone drug delivery system

[0219] In some embodiments, the device may include an elastic polymer drug matrix as described in WO2015 / 200752, which is incorporated herein by reference in its entirety. Device comprising a plurality of release portions

[0220] In certain embodiments, the device includes at least two drug release portions, and as described in WO2011 / 031855, which is hereby incorporated by reference in its entirety, at least one release portion releases drug at a different rate than another release portion. The release portions can achieve different release rates, in particular, by having different configurations, by containing different drug formulations, or by using different release mechanisms or combinations thereof. The release portions may be combined to achieve a desired release profile. For example, the device may include release portions that, in particular, exhibit different inductions or lag times before the start of the initial release, release drug at different rates or according to different release curves after the start of release, or release drug over different periods until the drug load is substantially depleted, or combinations thereof. The different release portions may be combined to achieve a desired release profile from the overall drug delivery device, for example, a release profile that exhibits a relatively short initial lag time followed by sustained release at a relatively constant rate over a long period.

[0221] In some embodiments, the device is loaded with drug in the form of several solid drug tablets that may be of a size smaller than conventional drug tablets. Since the device controls the release of the drug into the body, the drug itself may contain little or no excipients that control drug release. Instead, the excipients present in the drug tablets may be present primarily or solely to facilitate the tableting process or solubilization in vivo. Thus, the device can provide a high drug payload on a volume or weight basis, and further the device may be small enough for in vivo deployment in a minimally invasive manner.

[0222] The drug housing can also enable the release (egress) of the drug in liquid or semi-solid form following implantation or in vivo solubilization. The wall may be formed from a drug-permeable material that allows drug efflux through the drug housing along its entire length. The wall may be formed from a material that is at least partially semi-permeable to the drug depending on the drug form. For example, the wall may be permeable to the drug in one form such as the charged form, but not in another form such as the uncharged form (e.g., base form vs. salt form). The wall may include one or more openings or passages formed completely through the wall such that the drug can exit the drug housing.

[0223] The drug housing contains the drug in the form of several solid drug tablets that are aligned within the drug housing in a series arrangement and encapsulated within the drug housing using a sealing structure such as a plug that closes the entry opening at the opposite end of the drug housing. A gap or crevice formed between adjacent drug tablets allows the drug tablets to move relative to each other, such that the device is flexible despite being loaded with the drug in solid form.

[0224] The drug portion may have any combination of the features or configurations described herein, an aperture may be provided, omitted, replaced with a through-porosity, or enhanced with additional apertures or through-porosities; the housing may have a porous wall including an open-cell structure or a closed-cell structure; one or more degradable timing structures or release modulating structures may accompany the housing, or any combination thereof.

[0225] The drug tablets may be arranged in any arrangement other than in series according to the three-dimensional arrangement of the drug housing. The drug tablets may be filled in any part of the drug housing that is not the entire exemplified drug housing. A filler such as a silicone adhesive may be filled and used in any part of the drug housing where the drug tablets are not loaded. Air may be used, increasing the buoyancy of the device. The composition of the drug tablets may be the same or may vary along the device. The drug may be in a form other than drug tablets, such as other liquid, semi-solid or solid forms (e.g., granules).

[0226] In certain embodiments, the drug delivery device includes at least two separate or divided drug portions with a single holding portion. The drug portions may each be separate drug housings with a holding portion, or the drug portions may be separate areas within a single drug housing with a holding portion.

[0227] Each drug portion may be defined by a part of the wall of the drug housing and at least one dividing structure that separates the drug portion from a second drug portion. The dividing structure may in particular be a plug inserted into the housing, such as a cylinder, sphere or disk, and is fixed in place by its size or using an adhesive. The dividing structure may be part of the housing formed directly there, such as by molding.

[0228] A device comprising at least two distinct parts may be suitable for the controlled release of at least two drug payloads from corresponding numbers of drug reservoirs. The two distinct parts may have the same or different configurations, as described herein. The two drug payloads may be the same as each other or different from each other with respect to, in particular, content such as active ingredient content or excipient content; form such as salt form or base form; state such as liquid, semi-solid or solid state; or combinations thereof. Thus, the two distinct parts can release the two drug payloads simultaneously or at different times, at the same rate or at different rates, via the same or different release mechanisms, or any combination thereof.

[0229] For example, one drug part may be configured to release its drug payload relatively rapidly after implantation, another drug part may be configured to undergo an induction time before the start of release, or a combination thereof. The start of release of the two payloads of different drug parts may be staggered. Examples of rapidly releasing drug parts include drug parts that act as relatively immediate-release osmotic pumps, such as silicone tubes with relatively thin walls, drug parts loaded with the drug in a rapidly releasing form, such as liquid form or specially formulated solid form, drug parts with relatively immediate-release degradable timing structures, or combinations thereof. Thus, the device can release the drug during the initial acute phase and during the maintenance phase.

[0230] As another example, one drug portion may be configured to release its drug payload at a relatively faster rate than other drug payloads. For example, one drug portion may contain a drug payload with low water solubility for diffusive release that starts relatively promptly after implantation, and another drug portion may contain a drug payload with high water solubility for osmotic release after a lag period. As another example, one drug portion may contain the drug payload in a liquid state for rapid release through an aperture having an immediate-degrading timing membrane, and another drug portion may contain another drug payload in a solid tablet for delayed release following solubilization in vivo. As yet another example, one drug portion may have a relatively hard wall, while another drug portion may have several apertures or pores formed to penetrate that wall, which can increase the release rate by diffusion, or a closed-cell porous wall that can increase the release rate by increasing the permeation of water or drug through the wall.

[0231] The release portions may be combined to achieve a desired release profile. For example, the device may include release portions that release the drug according to different rates or different release curves after the start of release, or release the drug over different periods until the drug load is substantially depleted, or combinations thereof, particularly showing different induction or lag times before the start of the first release. The different release portions may be combined to achieve a desired release profile from the overall drug delivery device, for example, a release profile showing a relatively short initial lag time followed by sustained release at a relatively constant rate over a long period.

[0232] By combining a plurality of different drug portions in a single device, the device can exhibit a desired release profile of the antimetabolite. The release profile from the device as a whole may be the sum of the release profiles of the individual portions, for example, a first portion showing a minimum lag time before the start of release, a second portion showing a short induction period during which an osmotic gradient develops, and a third portion showing a long delay before the start due to the dissolution or decomposition of the degradable structure. Once release begins from any one portion, the release rate may be relatively zero order for an extended period, followed by a period of decay. It should be noted that the three different portions are examples, and any number or combination of individual portions may be used to achieve the desired release profile.

[0233] Since the different drug portions are simply separated areas within a single tubular housing, the device may advantageously be relatively simple for construction and deployment. Further, the different drug portions exhibit different release profiles due to different drug payloads, aperture arrangements, and degradable timing structures. In other embodiments where the drug portions use, for example, different materials, thicknesses, or walls of a porous cell structure, the housing may have varying lengths and separate drug housings may be used. Thus, sustained release may be achieved in a variety of ways. Gel

[0234] In another embodiment, the coating substance may be applied intravesically to the bladder wall (e.g., to the urothelial area within the bladder), and the coating substance includes an antimetabolite or other drug, and one or more excipient materials that promote adhesion of the coating substance to the bladder wall and provide sustained slow release of the drug over the treatment period. The coating substance may be a mucoadhesive formulation such as a gel, ointment, cream, paste, film, emulsion gel, tablet, polymer, or a combination thereof. Examples of mucoadhesive formulation polymers may include hydrogels or hydrophilic polymers, polycarbophil (i.e., carbopol, etc.), chitosan, polyvinylpyrrolidone (PVP), lectin, polyethylene glycolated polymers, cellulose, or a combination thereof. Suitable celluloses may include methylcellulose (MC), carboxymethylcellulose (CMC), hydroxypropylcellulose (HPC), or a combination thereof. The coating substance may include a permeation enhancer. Non-limiting examples of permeation enhancers may include dimethyl sulfoxide (DMSO), sodium carboxymethylcellulose (NaCMC), lipids, surfactants, or a combination thereof. The coating substance may be deployed intravesically so that the coating substance can bind to the bladder wall.

[0235] The coating substance may be deployed within the bladder using a deployment device. The deployment device may be any device designed to guide the body's natural lumen to reach the intended implantation site. For deployment within the bladder, the deployment device is sized and shaped to pass through the patient's urethra into the bladder. The deployment device may be a known device such as a catheter or cystoscope or a specially designed device. The deployment device is used to deploy the coating substance within the body and is then removed from the body, with all of the coating substance being implanted into the body. Once implanted, the coating substance can release drugs to the body over a long period of time. An equivalent procedure can be used to deploy either the devices or drugs described herein to other parts of the body through other natural lumens. For example, the deployment device can be used to deploy a liquid drug or drug formulation into the bladder by passing the deployment device through the urethra. Device Containing an Antimetabolite and a Second Agent

[0236] In some embodiments, the intravesical (within the bladder) devices provided herein contain an immunomodulatory agent. In some of these embodiments, the intravesical (within the bladder) devices provided herein contain an immunomodulatory agent and an antimetabolite. In some embodiments, the immunomodulatory agent and the antimetabolite are delivered at different rates. III. Kit

[0237] A kit containing an antimetabolite and an immunomodulatory agent is provided herein. In some embodiments, the kit contains an intravesical (within the bladder) device containing an antimetabolite. In some embodiments, the kit contains an intravesical (within the bladder) device containing an antimetabolite packaged with an immunomodulatory agent. In some embodiments, the kit contains an intravesical (within the bladder) device containing an antimetabolite and an immunomodulatory agent. IV. Exemplary Embodiments A method for treating urothelial carcinoma of the lower urinary tract in an individual, comprising the step of administering to the individual an effective amount of an antimetabolite, wherein the antimetabolite is delivered locally to the bladder. A method for enhancing an immune response against urothelial carcinoma of the lower urinary tract in an individual, comprising the step of administering to the individual an effective amount of an antimetabolite, wherein the antimetabolite is delivered locally to the bladder. A method for reducing recurrence or progression of urothelial carcinoma of the lower urinary tract in an individual, comprising the step of administering to the individual an effective amount of an antimetabolite, wherein the antimetabolite is delivered locally to the bladder. A method for improving the tumor microenvironment for cancer immunotherapy in an individual having urothelial carcinoma of the lower urinary tract, comprising the step of administering to the individual an effective amount of an antimetabolite, wherein the antimetabolite is delivered locally to the bladder. A method for sensitizing an individual having urothelial carcinoma of the lower urinary tract for radiotherapy, comprising the step of administering to the individual an effective amount of an antimetabolite, wherein the antimetabolite is delivered locally to the bladder. The method according to any one of embodiments 1 to 5, wherein the antimetabolite is a nucleoside analog. The method according to embodiment 6, wherein the antimetabolite is gemcitabine. The method according to any one of embodiments 1 to 7, wherein the antimetabolite is delivered continuously into the bladder over a period of at least about 24 hours. The method according to any one of embodiments 1 to 8, wherein the antimetabolite is delivered at a first release rate during a first period of delivery, followed by a second period of delivery having a second release rate. The method according to any one of embodiments 1 to 9, wherein the antimetabolite is delivered at a first dose during a first period of delivery, followed by a second dose during a second period of delivery. The method according to embodiment 9 or 10, wherein the first period and the second period are continuous. Embodiment 12. The method according to embodiment 9 or 10, wherein the first period and the second period are separated by a drug holiday period. Embodiment 13. The method according to any one of embodiments 1 to 9, wherein the antimetabolite is delivered at a dose of about 1 mg / day to about 300 mg / day. Embodiment 14. The method according to any one of embodiments 1 to 13, wherein the concentration of gemcitabine in urine is about 0.1 μg / mL to about 200 μg / mL during the delivery period. Embodiment 15. The method according to embodiment 14, wherein the concentration of the antimetabolite in urine is about 1 μg / mL to about 10 μg / mL during the delivery period. Embodiment 16. The method according to embodiment 15, wherein the concentration of the antimetabolite in urine is about 10 μg / mL during the delivery period. Embodiment 17. The method according to any one of embodiments 1 to 16, wherein the concentration of the antimetabolite in the plasma of the individual is less than about 1 μg / ml. Embodiment 18. The method according to any one of embodiments 1 to 17, wherein the ratio of the antimetabolite in the urine of the individual to the antimetabolite in the plasma is greater than about 500:1 upon delivery of the antimetabolite. Embodiment 19. The method according to any one of embodiments 1 to 18, wherein the antimetabolite is delivered over at least one month, each antimetabolite delivery period is at least one day, and the interval between each antimetabolite delivery period is about one week or less. Embodiment 20. a) A first antimetabolite delivery period in which the concentration of the antimetabolite in the urine of the individual is at least about 0.1 μg / mL; b) A drug holiday period; and c) A second antimetabolite delivery period in which the concentration of the antimetabolite in the urine of the individual is higher than about 0.1 μg / mL. The method according to any one of embodiments 1 to 19. Embodiment 21. The method according to embodiment 20, wherein the concentration of the antimetabolite in urine is higher than about 1 μg / mL for at least half of the drug holiday period. Embodiment 22. The method according to any one of embodiments 1 to 21, further comprising the step of administering to the individual an effective amount of a second agent. Embodiment 23. The second agent is delivered at the time when the delivery of the antimetabolite is initiated. The method according to Embodiment 22. Embodiment 24. The method according to Embodiment 22, wherein the second agent is delivered before the delivery of the antimetabolite is initiated. Embodiment 25. The method according to Embodiment 22, wherein the second agent is delivered after the delivery of the antimetabolite is initiated. Embodiment 26. The method according to Embodiment 22, wherein the second agent is delivered after the delivery of the antimetabolite is terminated. Embodiment 27. The method according to any one of Embodiments 22 to 26, wherein the antimetabolite delivery period and the second agent delivery period overlap with each other. Embodiment 28. The method according to any one of Embodiments 22 to 26, wherein the antimetabolite delivery period and the second agent delivery period are non-overlapping. Embodiment 29. The method according to any one of Embodiments 22 to 28, wherein the second agent is delivered systemically. Embodiment 30. The method according to any one of Embodiments 22 to 28, wherein the second agent is delivered locally. Embodiment 31. The method according to any one of Embodiments 22 to 30, wherein the second agent is delivered systemically at a first time of the second agent delivery period, and then local delivery at a second time of the second agent delivery period continues. Embodiment 32. The method according to any one of Embodiments 22 to 30, wherein the second agent is delivered locally at a first time of the second agent delivery period, and then systemic delivery at a second time of the second agent delivery period continues. Embodiment 33. The method according to Embodiments 31 and 32, wherein the first time of the second agent delivery period and the second time of the second agent delivery period are separated by at least about one month. Embodiment 34. The method according to Embodiment 22, wherein the antimetabolite and the second agent are delivered simultaneously. Embodiment 35. The method according to Embodiment 34, wherein the antimetabolite and the second agent are delivered via a single delivery device. Embodiment 36. The method according to Embodiment 35, wherein the antimetabolite and the second agent are delivered at the same release rate. Embodiment 37. The method according to embodiment 35, wherein the antimetabolite and the second agent are delivered at different release rates. Embodiment 38. The method according to any one of embodiments 34 to 37, further comprising the step of delivering the second agent separately from the antimetabolite. Embodiment 39. The method according to embodiment 38, wherein the second agent is systemically delivered. Embodiment 40. The method according to embodiment 38, wherein the second agent is locally delivered. Embodiment 41. The method according to any one of embodiments 22 to 40, wherein the second agent is a chemotherapeutic agent. Embodiment 42. The method according to embodiment 41, wherein the second agent is selected from the group consisting of paclitaxel, docetaxel, carboplatin, cisplatin, and oxaliplatin. Embodiment 43. The method according to any one of embodiments 22 to 40, wherein the second agent is an immunomodulatory agent. Embodiment 44. The method according to embodiment 43, wherein the immunomodulatory agent is an immune checkpoint inhibitor. Embodiment 45. The method according to embodiment 44, wherein the immune checkpoint inhibitor is an inhibitor of an immune checkpoint protein selected from the group consisting of PD-L1, CTLA4, PD-L2, PD-1, B7-H3, B7-H4, HVEM, B and T lymphocyte attenuator (BTLA), killer inhibitory receptor (KIR), GAL9, TIM3, A2AR, LAG-3, phosphatidylserine, CD27, TNF-α, CD33, Siglec-5, Siglec-7, Siglec-9, and Siglec-11. Embodiment 46. The method according to embodiment 43, wherein the immunomodulatory agent is an agonist of a costimulatory immune molecule. Embodiment 47. The method according to embodiment 46, wherein the costimulatory immune molecule is selected from the group consisting of CD40, OX40, ICOS, CD28, CD137 / 4-1BB, CD27, IL-10, TGF-beta, TOR receptor, and glucocorticoid-induced TNFR-related protein GITR. Embodiment 48. The method according to any one of Embodiments 1 to 47, wherein the individual does not receive radiation therapy. Embodiment 49. The method according to any one of Embodiments 1 to 48, further comprising radiation therapy. Embodiment 50. The method according to any one of Embodiments 1 to 49, wherein the antimetabolite is delivered in a neoadjuvant setting. Embodiment 51. The method according to any one of Embodiments 1 to 49, wherein the antimetabolite is delivered in an adjuvant setting. Embodiment 52. The method according to any one of Embodiments 1 to 51, further comprising a third treatment including surgery, and wherein the delivery of the antimetabolite to the individual is initiated at the time of surgery. Embodiment 53. The method according to any one of Embodiments 1 to 52, wherein the delivery of the antimetabolite to the individual is initiated during cystoscopy. Embodiment 54. The method according to any one of Embodiments 1 to 53, wherein the antimetabolite is delivered into the bladder by a intravesical delivery device. Embodiment 55. The method according to Embodiment 54, wherein the intravesical device comprises a housing configured for intravesical insertion; and a dosage form comprising the antimetabolite, the housing being configured to hold the dosage form and release the antimetabolite in an amount effective for the treatment of urothelial cancer. Embodiment 56. The method according to any one of Embodiments 54 to 55, wherein the intravesical drug delivery device comprises a housing that contains the antimetabolite, controllably releases it, and is elastically deformable between a retention shape configured to hold the device in the individual's bladder and a deployment shape for passage of the device through the individual's urethra. Embodiment 57. The method according to Embodiment 56, wherein the device comprises a drug reservoir lumen bounded by a first wall and a second wall, the first wall being impermeable to the drug, and the second wall being permeable to the antimetabolite. Embodiment 58. The method according to Embodiment 57, wherein the first wall is cylindrical. Embodiment 59. The method according to any one of Embodiments 57 to 58, wherein the second wall is disk-shaped. Embodiment 60. The method according to any one of Embodiments 54 to 59, wherein the intravesical drug delivery device comprises at least two drug reservoir lumens. Embodiment 61. The method according to any one of Embodiments 54 to 60, wherein the antimetabolite is released from the device by osmotic pressure. Embodiment 62. The method according to any one of Embodiments 54 to 61, wherein the antimetabolite is released from the device by diffusion. Embodiment 63. The method according to any one of Embodiments 54 to 62, wherein the antimetabolite contained in the housing is in a non-liquid form. Embodiment 64. The method according to Embodiment 63, wherein the non-liquid form is selected from the group consisting of tablets, granules, semi-solids, capsules, and combinations thereof. Embodiment 65. The method according to any one of Embodiments 1 to 64, wherein the urothelial cancer is bladder cancer. Embodiment 66. The method according to Embodiment 65, wherein the bladder cancer is locally advanced bladder cancer or metastatic bladder cancer. Embodiment 67. The method according to any one of Embodiments 64 to 65, wherein the bladder cancer is muscle-invasive bladder cancer. Embodiment 68. The method according to any one of Embodiments 64 to 65, wherein the bladder cancer is non-muscle-invasive bladder cancer. Embodiment 69. The method according to any one of Embodiments 64 to 65, wherein the bladder cancer is carcinoma in situ. Embodiment 70. The method according to any one of Embodiments 64 to 65, wherein the bladder cancer is BCG (Bacillus Calmette-Guérin) - refractory cancer or papillary bladder cancer. Embodiment 71. The method according to any one of Embodiments 1 to 70, wherein the individual is a human. Embodiment 72. The method according to any one of Embodiments 1 to 71, wherein the individual is unsuitable for systemic treatment. Embodiment 73. The method according to any one of Embodiments 1 to 72, wherein the individual has a compromised immune system. Embodiment 74. The method according to any one of Embodiments 1 to 73, wherein the individual has a high level of immune checkpoint protein. Embodiment 75. The method according to any one of Embodiments 1 to 73, wherein the individual has a low level of immune checkpoint protein. Embodiment 76. The method according to any one of Embodiments 1 to 75, wherein the individual has a high level of nucleoside transporter. Embodiment 77. The method according to any one of Embodiments 1 to 75, wherein the individual has a low level of nucleoside transporter. Embodiment 78. The method according to any one of Embodiments 1 to 77, wherein the antimetabolite is gemcitabine, and the method further comprises determining the gemcitabine / metabolite ratio in urine, and a ratio below the threshold indicates an effective treatment. Embodiment 79. A kit for treating urothelial carcinoma of the lower urinary tract in an individual, comprising a) an antimetabolite and b) a second agent, wherein the antimetabolite is in a device for local delivery to the bladder. Embodiment 80. The kit according to Embodiment 79, wherein the antimetabolite is gemcitabine. Embodiment 81. The kit according to Embodiment 79 or 80, wherein the second agent is an immunomodulatory agent. Embodiment 82. A delivery device for local delivery of an antimetabolite and a second agent to the bladder of an individual, comprising a housing containing the antimetabolite and the immunomodulatory agent, wherein the housing is configured to provide local release of the antimetabolite and the second agent into the bladder of the individual. Embodiment 83. The delivery device according to Embodiment 82, wherein the antimetabolite is gemcitabine. Embodiment 84. The delivery device according to Embodiment 82 or 83, wherein the second agent is an immunomodulatory agent. Embodiment 85. The method according to any one of Embodiments 54 to 56, wherein the intravesical drug delivery device comprises a housing defining a reservoir; a first unit contained within the reservoir, the first unit containing an antimetabolite; and a second unit contained within the reservoir at a location separate from the first unit, the second unit containing a functional agent that promotes in vivo release of the drug from the housing. Embodiment 86. A method for treating muscle-invasive bladder cancer in an individual, comprising the step of locally delivering an effective amount of gemcitabine to the bladder, wherein the gemcitabine is delivered continuously for at least 24 hours. Embodiment 87. A method for bladder preservation in an individual, comprising the step of locally delivering an effective amount of gemcitabine to the bladder, wherein the gemcitabine is delivered continuously for at least 24 hours. Embodiment 88. The method according to embodiment 86 or 87, wherein the gemcitabine is delivered by an intravesical device. Embodiment 89. The method according to embodiment 88, wherein the intravesical device comprises a housing configured for intravesical insertion; and a dosage form containing an antimetabolite, the housing being configured to hold the dosage form and release the antimetabolite in an amount effective for the treatment of urothelial cancer. Embodiment 90. The method according to embodiment 88 or 89, wherein the intravesical drug delivery device comprises a housing that contains an antimetabolite, controllably releases it, and is elastically deformable between a holding shape configured to hold the device in the individual's bladder and a deployment shape for passage of the device through the individual's urethra. Embodiment 91. The method according to any one of embodiments 88 to 90, wherein the intravesical device contains 225 mg of gemcitabine. Embodiment 92. The method according to any one of embodiments 86 to 91, wherein the gemcitabine is continuously delivered to the individual's bladder over a period of 24 hours to 3 weeks. Embodiment 93. The method according to any one of embodiments 86 to 92, wherein the gemcitabine is continuously delivered to the individual's bladder for 7 days. Embodiment 94. The method according to any one of embodiments 86 to 93, comprising two gemcitabine delivery periods. Embodiment 95. The method according to embodiment 94, wherein the first and second gemcitabine delivery periods are each 7 days. Embodiment 96. The method according to embodiment 94 or 95, wherein the first and second gemcitabine delivery periods are separated by a 14-day drug-free period. Embodiment 97. The method according to any one of Embodiments 86 to 96, wherein the individual is not suitable for radical cystectomy. Embodiment 98. The method according to any one of Embodiments 86 to 97, wherein the individual cannot tolerate chemotherapy with agents other than systemic chemotherapy and / or antimetabolites. Embodiment 99. The method according to any one of Embodiments 86 to 98, wherein the individual does not undergo radical cystectomy. Embodiment 100. A method for treating non-muscle invasive bladder cancer in an individual, comprising the step of locally delivering gemcitabine to the bladder, wherein the gemcitabine is delivered continuously for at least 24 hours. Embodiment 101. The method according to Embodiment 100, wherein the gemcitabine is delivered by an intravesical device. Embodiment 102. The method according to Embodiment 101, wherein the intravesical device comprises a housing configured for intravesical insertion; and a dosage form containing an antimetabolite, and the housing is configured to hold the dosage form and release the antimetabolite in an amount effective for treating urothelial cancer. Embodiment 103. The method according to Embodiment 101 or 102, wherein the intravesical drug delivery device comprises a housing containing an antimetabolite, controllably releasing it, and being elastically deformable between a holding shape configured to hold the device in the individual's bladder and a deployment shape for passage of the device through the individual's urethra. Embodiment 104. The method according to any one of Embodiments 101 to 103, wherein the intravesical device contains 225 mg of gemcitabine. Embodiment 105. The method according to any one of Embodiments 100 to 105, wherein the gemcitabine is continuously delivered to the individual's bladder for a period of 24 hours to 3 weeks. Embodiment 106. The method according to any one of Embodiments 100 to 106, wherein the gemcitabine is continuously delivered to the individual's bladder for 7 days. Embodiment 107. The method according to any one of Embodiments 100 to 106, comprising a first gemcitabine delivery period and a second gemcitabine delivery period. Embodiment 108. The method according to Embodiment 107, wherein the first and second gemcitabine delivery periods are each 7 days. Embodiment 109. The method according to Embodiment 107 or 108, wherein the first and second gemcitabine delivery periods are separated by a 14-day drug holiday period. Embodiment 110. The method according to any one of Embodiments 86 to 109, wherein the individual is a human. Embodiment 111. The method according to any one of Embodiments 7 to 78, wherein gemcitabine is continuously delivered to the bladder of an individual over 7 days. Embodiment 112. The method according to any one of Embodiments 7 to 78, wherein gemcitabine is continuously delivered to the bladder of an individual over 3 weeks. Embodiment 113. The method according to any one of Embodiments 7 to 78, 111, or 112, comprising two gemcitabine delivery periods. Embodiment 114. The method according to Embodiment 113, wherein the first and second gemcitabine delivery periods are each 7 days. Embodiment 115. The method according to Embodiment 113, wherein the first and second gemcitabine delivery periods are each 3 weeks. Embodiment 114. The method according to any one of Embodiments 113 to 115, wherein the first and second gemcitabine delivery periods are separated by a drug holiday period. Embodiment 115. The method according to Embodiment 114, wherein the drug holiday period is 14 days. Embodiment 116. The method according to Embodiment 114, wherein the drug holiday period is 14 days to 12 weeks. Embodiment 117. The method according to any one of Embodiments 100 to 104, wherein gemcitabine is continuously delivered to the bladder of an individual over 3 weeks. Embodiment 118. The method according to Embodiment 107, wherein the first gemcitabine delivery period and the second gemcitabine delivery period are each 3 weeks.

Examples

[0238] (Example 1) The orthotopic bladder cancer model was developed in rats to enable the evaluation of the efficacy of continuous gemcitabine administration to the bladder in the treatment of human bladder cancer cell lines. Thymus-deficient nude rats were cannulated on day 0. On day 3, rats were injected with fluorescently labeled T24 human bladder cancer cells. Tumors were observable on day 5 of the study. Gemcitabine perfusion was initiated on day 6 and continued until day 11. Three concentrations of gemcitabine were examined: 90 μg / ml, 180 μg / ml, and 350 μg / ml. As shown in Figure 1, continuous administration of 90 μg / ml of gemcitabine over a 5-day study period resulted in a significant reduction in tumor volume compared to untreated controls. The antitumor effect increased with increasing administered concentration of gemcitabine.

[0239] After 11 days, the bladders were removed and subjected to histological analysis. A strong inflammatory response was observed for all three gemcitabine concentrations examined. The higher the concentration, the larger the area of necrosis, and infiltration of inflammatory cells was observed at the drug release site.

[0240] No significant differences were found in the urine and blood parameters measured in rats treated with gemcitabine. Hematuria was observed in all perfused animals.

[0241] Gemcitabine was tolerable in all perfusion groups with mild to moderate weight loss. Deaths (2 / 6) were observed in the high-dose gemcitabine treatment (350 μg / ml). (Example 2)

[0242] The minipig model was developed to investigate the effect of administering gemcitabine locally and continuously in the bladder using an intravesical (within the bladder) device. For this study, gemcitabine was administered continuously to minipigs for one week using an intravesical (within the bladder) device. The intravesical (within the bladder) device was removed on day 7. Following removal of the device, the concentrations of gemcitabine and active metabolites were measured in the urine of minipigs. Based on the levels of gemcitabine and active metabolites in the urine, the therapeutic gemcitabine levels in the bladder tissue were estimated. Surprisingly, the levels suitable for gemcitabine treatment were well sustained even after the device was removed. (Example 3)

[0243] The pilot study conducted used male Sprague-Dawley rats to determine the pharmacokinetic and pharmacodynamic properties of administering gemcitabine locally and continuously to the bladder. The rats were fitted with an intravesical cannula (IVBC), and radiolabeled 14 C-gemcitabine was perfused at a rate of 300 μL / hour at a gemcitabine concentration of 3.85 mg / mL for 6 or 24 hours. The gemcitabine concentrations in various tissue layers were measured. Surprisingly, as shown in Figure 3, gemcitabine can penetrate deep bladder tissue. The radiolabel was most concentrated in the adventitia and epithelium, followed by muscle and lamina propria in that order. (Example 4)

[0244] An isogeneic rat model was developed to evaluate the treatment efficacy and immune effects of continuous local administration to the bladder. Wistar rats were cannulated on day 0, and NBT-II rat bladder tumor cells were injected on day 3. The tumors were allowed to grow for 5 days before perfusion was initiated on day 8. Gemcitabine was perfused at a concentration of 90 μg / ml or 180 μg / ml from days 8 to 13 of the study. The rats were euthanized on day 14. Samples from tumors, spleen, blood, and plasma were collected for histopathology and immunohistochemistry, flow cytometry, and cytokine profiling.

[0245] The levels of activated CD8+ and CD4+ T cells were also measured in the tumor microenvironment compared to the levels of CD4+ and CD8+ regulatory cells. As shown in Figure 4, treatment with gemcitabine decreased the ratio of activated CD4+ and CD8+ T cells to regulatory T cells in the tumor microenvironment. The levels of activated CD4+ and CD8+ cells increased in the spleens of rats treated with gemcitabine (Figure 5). Without being bound by theory, the effects observed for activated CD4+ and CD8+ cells may result from enhanced T cell transport and clonal expansion following release of bladder tumor antigens into the bloodstream.

[0246] Plasma TGFβ and IL-10 levels were also measured following delivery of gemcitabine. As shown in Figure 6, the levels of TGFβ decreased in rats treated with gemcitabine compared to control animals. Inhibition of TGFβ is known to impair Treg activation. As shown in Figure 7, IL-10 levels increased with delivery of gemcitabine.

[0247] These results demonstrate that sustained and local delivery of gemcitabine elicits an immune response. (Example 5)

[0248] The ongoing Phase 1b study, TAR-200-101, is designed to evaluate the safety and tolerability up to 2 doses cycles of gemcitabine administered intravesically over 7 days at a dose of 225 mg, divided by a 14-day drug-free period using the GemRIS system, in patients with confirmed muscle-invasive transitional cell carcinoma of the bladder (> / = clinical and pathologic stage pT2a) who are planned to undergo radical cystectomy (RC) with concomitant lymph node dissection.

[0249] The Gemcitabine Releasing Intravesical System (GemRIS) is placed into the bladder through an inserter on Day 0 of the study and removed on Day 7 of the study. GemRIS gradually releases gemcitabine during the 7-day indwelling period. A second GemRIS is placed into the bladder on Day 21 of the study and removed on Day 28 of the study, which is the day of TURBT. GemRIS is a passive, non-absorbable gemcitabine-releasing intravesical (intra-bladder) system whose main mode of action is the sustained release of gemcitabine into the bladder over 7 days.

[0250] In Arm 1, there is a residual tumor after TURBT. TAR-200 (GemRIS) is placed into the bladder through an inserter on Day 0 of the study and removed on Day 7 of the study. TAR-200 gradually releases gemcitabine during the 7-day indwelling period. A second TAR-200 is placed into the bladder on Day 21 of the study and removed on Day 28 of the study, which is the day of radical cystectomy (RC).

[0251] In Arm 2, there is no residual tumor after TURBT. TAR-200 (GemRIS) is placed into the bladder through an inserter on Day 0 of the study and removed on Day 7 of the study. TAR-200 gradually releases gemcitabine during the 7-day indwelling period. A second TAR-200 is placed into the bladder on Day 21 of the study and removed on Day 28 of the study, which is the day of radical cystectomy (RC).

[0252] Patients have histological proof of muscle-invasive transitional cell carcinoma of the bladder (Stages II - IIIb). Patients with signs of metastatic nodal disease to only the obturator or presacral lymph nodes may be included. Patients must have no visible residual tumor measured at more than 3 cm after TURBT. Patients included in the study are considered ineligible for cisplatin-based chemotherapy or have refused cisplatin-based chemotherapy. Prior radiotherapy is allowed provided that radiotherapy has not been administered to the bladder. Patients must be eligible and willing to undergo cystoscopy in a study of the removal of the investigational product and radical cystectomy after treatment.

[0253] The primary evaluation item is the number of participants who had treatment-emergent adverse events (TEAEs) coded using MedDRA and classified by severity using CTCAE v4.0. The secondary evaluation items are the number and percentage of participants who were tolerant of GemRIS indwelling on days 1 to 7 and days 21 to 28. Plasma and urine levels of dFdC and dFdU are also measured. The secondary efficacy measures also include the following:

[0254] 1. The number of participants who were tolerant of TAR-200 indwelling [period: from day 0 to day 7]

[0255] 2. The percentage of participants who were tolerant of TAR-200 indwelling [period: from day 0 to day 7]

[0256] 3. The number of participants who were tolerant of TAR-200 indwelling [period: from day 21 to day 28]

[0257] 4. The percentage of participants who were tolerant of TAR-200 indwelling [period: from day 21 to day 28]

[0258] 5. Cmax, plasma dFdU. Analysis of the Cmax (maximum concentration reached over time) of diflourodeoxyuridine (dFdU) in plasma. [Period: from day 0 to day 28]

[0259] 6. Tmax, plasma dFdU. Analysis of the Tmax (day on which the maximum concentration was reached) of diflourodeoxyuridine (dFdU) in plasma. [Period: from day 0 to day 28]

[0260] 7. Cavg, plasma dFdU. Analysis of descriptive statistics of the concentration of diflourodeoxyuridine (dFdU) in plasma (e.g., sample size, mean and median, quartiles, minimum and maximum values, and box plots). [Period: from day 0 to day 28]

[0261] 8. Cmax, Plasma dFdC. Analysis of the Cmax (maximum concentration reached over time) of gemcitabine (difluorodeoxycytidine hydrochloride - dFdC) in plasma. [Period: From day 0 to day 28]

[0262] 9. Tmax, Plasma dFdC. Analysis of the Tmax (day on which the maximum concentration was reached) of gemcitabine (difluorodeoxycytidine hydrochloride - dFdC) in plasma [Period: From day 0 to day 28]

[0263] 10. Cavg, Plasma dFdC. Analysis of the descriptive statistics (e.g., sample size, mean and median, quartiles, minimum and maximum values, and box plot) of the concentration of gemcitabine (difluorodeoxycytidine hydrochloride - dFdC) in plasma [Period: From day 0 to day 28].

[0264] 11. Cmax, Urine dFdU (Arm 1 only). Analysis of the Cmax (maximum concentration reached over time) of difluorodeoxyuridine (dFdU) in urine. [Period: From day 0 to day 28]

[0265] 12. Tmax, Urine dFdU (Arm 1 only). Analysis of the Cmax (maximum concentration reached over time) of difluorodeoxyuridine (dFdU) in urine. [Period: From day 0 to day 28]

[0266] 13. Tmax, Urine dFdU (Arm 1 only). Analysis of the Cmax (maximum concentration reached over time) of difluorodeoxyuridine (dFdU) in urine. [Period: From day 0 to day 28]

[0267] 14. Cavg, Urine dFdU (Arm 1 only). Analysis of the descriptive statistics (e.g., sample size, mean and median, quartiles, minimum and maximum values, and box plot) of the concentration of difluorodeoxyuridine (dFdU) in urine. [Period: From day 0 to day 28]

[0268] 15. Cmax, urinary dFdC (arm 1 only). Analysis of the Cmax (maximum concentration reached over time) of gemcitabine (difluorodeoxycytidine hydrochloride - dFdC) in urine [Period: from day 0 to day 28]

[0269] 16. Tmax, urinary dFdC (arm 1 only). Analysis of the Tmax (day on which the maximum concentration was reached) of gemcitabine (difluorodeoxycytidine hydrochloride - dFdC) in urine [Period: from day 0 to day 28].

[0270] 17. Cavg, urinary dFdC (arm 1 only). Analysis of the descriptive statistics of the concentration of gemcitabine (difluorodeoxycytidine hydrochloride - dFdC) in urine (e.g., sample size, mean and median, quartiles, minimum and maximum values, and box plot). [Period: from day 0 to day 28]

[0271] 18. Preliminary antitumor effect evaluated in tumor material (after treatment) for immunohistochemical tissue biomarker (AKT) of drug-induced cell death (arm 1) [Period: Antitumor analysis is performed at the study visit on day 28.]

[0272] 19. Preliminary antitumor effect evaluated in tumor material (after treatment) for immunohistochemical tissue biomarker (CD31) of drug-induced cell death (arm 1). [Period: Antitumor analysis is performed at the study visit on day 28.]

[0273] 20. Preliminary antitumor effect evaluated in tumor material (after treatment) for immunohistochemical tissue biomarker (Ki67) of drug-induced cell death (arm 1) [Period: Antitumor analysis is performed at the study visit on day 28.]

[0274] 21. Preliminary antitumor effect evaluated in tumor material (after treatment) for immunohistochemical tissue biomarker (TUNEL) of drug-induced cell death (arm 1) [Period: Antitumor analysis is performed at the study visit on day 28.]

[0275] 22. Preliminary antitumor effect (Arm 1) evaluated on tumor material (after treatment) for immunohistochemical tissue biomarker (CD4) of drug-induced cell death [Period: Antitumor analysis is performed at the clinic visit on the 28th study day.]

[0276] 23. Preliminary antitumor effect (Arm 1) evaluated on tumor material (after treatment) for immunohistochemical tissue biomarker (CD8) of drug-induced cell death [Period: Antitumor analysis is performed at the clinic visit on the 28th study day.]

[0277] 24. Preliminary antitumor effect (Arm 1) evaluated on tumor material (after treatment) for immunohistochemical tissue biomarker (PD-L1) of drug-induced cell death [Period: Antitumor analysis is performed at the clinic visit on the 28th study day.]

[0278] 25. Preliminary antitumor effect (Arm 2) evaluated on tumor material (after treatment) for immunohistochemical tissue biomarker (AKT) of drug-induced cell death [Period: Antitumor analysis is performed at the clinic visit on the 42nd study day.]

[0279] 26. Preliminary antitumor effect (Arm 2) evaluated on tumor material (after treatment) for immunohistochemical tissue biomarker (CD31) of drug-induced cell death [Period: Antitumor analysis is performed at the clinic visit on the 42nd study day.]

[0280] 27. Preliminary antitumor effect (Arm 2) evaluated on tumor material (after treatment) for immunohistochemical tissue biomarker (Ki67) of drug-induced cell death [Period: Antitumor analysis is performed at the clinic visit on the 42nd study day.]

[0281] 28. Preliminary antitumor effect (Arm 2) evaluated on tumor material (after treatment) for immunohistochemical tissue biomarker (TUNEL) of drug-induced cell death [Period: Antitumor analysis is performed at the clinic visit on the 42nd study day.] 29. Preliminary antitumor effect (Arm 2) evaluated on tumor material (after treatment) for immunohistochemical tissue biomarker (CD4) of drug-induced cell death [Period: Antitumor analysis is performed at the clinic visit on the 42nd study day.]

[0282] 29. Preliminary anti-tumor effect (Arm 2) evaluated in tumor material (after treatment) for immunohistochemical tissue biomarker of drug-induced cell death (CD8) [Period: Anti-tumor analysis is performed at the study visit on Day 42.]

[0283] 30. Preliminary anti-tumor effect (Arm 2) evaluated in tumor material (after treatment) for immunohistochemical tissue biomarker of drug-induced cell death (PD-L1) [Period: Anti-tumor analysis is performed at the study visit on Day 42.]

[0284] Use the following eligibility criteria: Minimum age of 18 years. Histological proof of muscle-invasive transitional cell carcinoma of the bladder (stages II - III). Subjects with signs of metastatic nodular disease to the obturator muscles or presacral lymph nodes only may be included (N1 M0). Subjects with any degree of fixation of the pelvic sidewall are ineligible. In Arm 1, subjects must have no visible residual tumor after TURBT. In Arm 2, subjects must be completely resected after restaged TURBT 2 - 6 weeks prior to Day 0 of the study (i.e., no visible tumor or the smallest possible tumor). Appropriate bone marrow, liver, and renal function as evaluated by the following requirements performed within 21 days prior to dosing: a. Hemoglobin ≥ 9.0 g / dL b. Absolute neutrophil count (ANC) ≥ 1,500 / mm3 c. Platelet count ≥ 100,000 / mm3 d. Total bilirubin ≤ 1.5 × ULN (upper limit of normal) e. Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) ≤ 2.5 × ULN f. Glomerular filtration rate (GFR) ≥ 30% (≥ 30 ml / min / 1.73 m2). Subjects must be willing to undergo cystoscopy in the study for removal of investigational product. Eligible and willing to undergo RC by the treating urologist. Subjects must not be considered ineligible for cisplatin-based combination chemotherapy by the treating medical oncologist. Subjects who are medically eligible for neoadjuvant cisplatin-based combination chemotherapy, decline this treatment option, and understand the risks and benefits of doing so. Prior radiation therapy is allowed provided that radiation therapy has not been administered to the bladder. Consent for disclosure of personal medical information and approval under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Age > 18 years at the time of consent.

[0285] Use the following exclusion criteria: Active malignancies within 12 months, excluding those treated with an expected curative outcome and with negligible risk of metastasis or death. Prior systemic chemotherapy for transitional cell carcinoma of the bladder. Any other prior systemic chemotherapy for non-urothelial carcinoma must have been completed more than 5 years prior to study initiation. Prior exposure to gemcitabine infusion. Other current intravesical chemotherapy. Concurrent clinically significant infections as determined by the treating investigator. The presence of any bladder or urethral anatomical features that may preclude the safe placement, retention, use, or removal of TAR-200 in the opinion of the investigator. A confirmed history of vesicoureteral reflux or the presence of an indwelling urinary catheter stent or nephrostomy tube at screening. Pelvic radiotherapy administered within less than 6 months prior to registration. Subjects who received radiotherapy more than 6 months prior to registration should not exhibit signs at cystoscopy or symptoms of radiation cystitis. A post-void residual (PVR) volume of more than 250 mL. Active, uncontrolled genitourinary bacterial, viral, or fungal infections, including urinary tract infections that are considered a contraindication to participation in the opinion of the investigator. Cutaneous / nail fungal infections are not excluded. Subjects with active herpes zoster (varicella-zoster virus infection) are excluded from the study. A history or presence of any serious cardiovascular, pulmonary, hepatic, renal, gastrointestinal, gynecological, endocrine, immunological, dermatological, neurological, or psychiatric disease or disorder that is considered a contraindication to participation in the opinion of the investigator. A history of diagnosis of neurogenic bladder. Concomitant immunosuppressive drug therapy such as methotrexate or TNF inhibitors within 2 weeks of study day 0, excluding steroids at a dose of 5 mg or less per day. Difficulty in providing blood samples. The presence of any condition (physical, mental, or social) that may affect the subject's return for scheduled visits and follow-up observations, including the unwillingness or inability to consent to informed consent or comply with the requirements of this protocol. Other unspecified reasons that, in the opinion of the investigator or TARIS, render the subject ineligible for registration.

[0286] It was administered to 10 subjects. There were no significant adverse events or interruptions related to the treatment, and no subject requested removal of GemRIS. Cystitis or gross hematuria was not reported. Furthermore, there were no signs of anemia, neutropenia, or thrombocytopenia related to the treatment typically seen with IV or systemic administration of gemcitabine, and no events that caused a delay in RC. There was also no chemical cystitis. Preliminary pharmacokinetic analysis for the 10 subjects was completed, demonstrating measurable urinary levels of gemcitabine and dFdU (intracellular metabolite). The plasma concentration of gemcitabine was lower than the limit of quantification assay (0.1 mcg / mL) in all plasma samples analyzed (n = 55). Low but quantifiable plasma concentrations of dFdU in the range of 0.104 - 0.284 mcg / mL were occasionally observed in 10 out of the 55 plasma samples analyzed.

[0287] All treatment subjects had a residual, grossly visible, exophytic, papillary tumor measuring 3 cm or greater in size, consistent with a large muscle-invasive disease. Notably, 5 of these 10 treatment subjects had no grossly visible tumor at the time of RC, suggesting a treatment effect during the 28-day dosing period. Of the remaining 5 subjects with a grossly visible tumor at RC, 3 showed a significant reduction in exophytic tumor volume, and the remaining 2 (each with pT3 stage disease) had persistent disease. Four of the 10 subjects, including 1 subject with a complete pathologic response, had no histological signs of residual muscle-invasive disease at the time of cystectomy (<pT2). Unexpectedly, 9 of the 10 subjects had no nodal involvement at the time of RC. The rate of nodal involvement in the historical series was 20-40%. Furthermore, none of the subjects were pathologically upstaged from their clinically diagnosed stage (cT2, cT3) at the time of RC to a final pathologic stage. Considering that 42% of patients with clinically staged MIBC are subsequently upstaged on final pathologic staging, this is surprising. Furthermore, recent studies have suggested that pathologic downstaging at the time of RC is associated with a better prognosis. The preliminary pathologic efficacy results to date are summarized in Table 1. The preliminary anti-tumor effect can be evaluated in tumor material (post-treatment) for immunohistochemical tissue biomarkers of drug-induced cell death (CD4, CD8, PD-L1, AKT, CD31, Ki67, TUNEL).

[0288] Several patients treated with GemRIS had inflammation around the tumor, but the surrounding urothelium that was not involved appeared normal and showed a significant anti-tumor effect. This is consistent with the gross findings observed after treatment with immunotherapy.

[0289] In addition to the significantly benign and safe profile seen to date, GemRIS has demonstrated remarkable and unexpected preliminary clinical efficacy using the 28-day window treatment currently approved in the cystectomy-eligible population. GemRIS may provide substantially higher benefits for cystectomy-ineligible patients for whom longer-term treatment is possible.

Table 1

[0290] The ongoing Phase 1b study, designated TAR-200-102, is designed to evaluate the safety and tolerability of the GemRIS system for 14 days of dosing at 225 mg, divided by a 7-day drug-free period, administered intravesically over 7 days in a 2-dose cycle of gemcitabine, in patients with low or intermediate risk of recurrence of non-muscle-invasive bladder cancer (NMIBC) between diagnosis and transurethral resection of bladder tumor (TURBT) over 28 days.

[0291] The Gemcitabine Releasing Intravesical System (GemRIS) is placed in the bladder on study Day 0 through an inserter and removed on study Day 7. GemRIS releases gemcitabine gradually over a 7-day dwell period. A second GemRIS is placed in the bladder on study Day 21 and removed on study Day 28, which is the day of TURBT. GemRIS is a passive, non-absorbable gemcitabine-releasing intravesical (intra-bladder) system, the main mode of action of which is the sustained release of gemcitabine into the bladder over 7 days.

[0292] Arm 1: Experiment: The 7-day regimen of TAR-200 (GemRIS) is placed in the bladder on study day 0 through an inserter and removed on study day 7. TAR-200 gradually releases gemcitabine during the 7-day indwelling period. A second TAR-200 is placed in the bladder on study day 21 and removed on study day 28, which is the day of TURBT. Drug: Gemcitabine-Releasing Intravesical System (GemRIS / TAR-200). TAR-200 is a passive, non-absorbable gemcitabine-releasing intravesical system whose main mode of action is the sustained release of gemcitabine into the bladder over the indwelling period.

[0293] Arm 2: Experiment: The 21-day regimen of TAR-200 is placed in the bladder on study day 0 through an inserter and removed on study day 21. TAR-200 gradually releases gemcitabine during the 21-day indwelling period. A second TAR-200 is placed in the bladder on study day 21 and removed on study day 42. Drug: Gemcitabine-Releasing Intravesical System (GemRIS) / TAR-200. TAR-200 is a passive, non-absorbable gemcitabine-releasing intravesical system whose main mode of action is the sustained release of gemcitabine into the bladder over the indwelling period.

[0294] Patients included in the study have a histologically confirmed history of low or intermediate risk of urothelial carcinoma of the bladder with a history excluding in situ (pTis) pathological stage pT1 (invasion into the lamina propria) carcinoma and high-grade disease that was determined to be resectable (pT2 or greater) and not infiltrating.

[0295] The primary evaluation item is the number of participants who developed treatment-emergent adverse events (TEAEs) coded using MedDRA and classified by severity using CTCAE v4.0 [Period: From the time of signing the informed consent form to the last study visit, up to day 59]. The secondary evaluation items are the number and percentage of participants who are tolerant of GemRIS indwelling on days 1 to 7 and days 21 to 28. Plasma and urine levels of dFdC and dFdU are also measured.

[0296] The preliminary anti-tumor effect is evaluated in tumor materials (after treatment) for the evaluation of immunohistochemical tissue biomarkers of drug-induced cell death (AKT, CD31, Ki67, TUNEL). The secondary evaluation items include the following:

[0297] 1. The number of participants who are tolerant of TAR-200 indwelling (Arm 1). [Period: From day 0 to day 7]

[0298] 2. The percentage of participants who are tolerant of TAR-200 indwelling (Arm 1). [Period: From day 0 to day 7]

[0299] 3. The number of participants who are tolerant of TAR-200 indwelling (Arm 1). [Period: From day 21 to day 28]

[0300] 4. The percentage of participants who are tolerant of TAR-200 indwelling (Arm 1). [Period: From day 21 to day 28]

[0301] 5. Cmax, plasma dFdU (Arm 1). Analysis of the Cmax (maximum concentration reached over time) of difluorodeoxyuridine (dFdU) in plasma. [Period: From day 0 to day 32]

[0302] 6. Tmax, plasma dFdU (Arm 1). Analysis of the Tmax (day on which the maximum concentration was reached) of difluorodeoxyuridine (dFdU) in plasma. [Period: From day 0 to day 32]

[0303] 7. Cavg, plasma dFdU (Arm 1). Analysis of descriptive statistics (such as sample size, mean and median, quartiles, minimum and maximum values, and box plots) of the concentration of difluorodeoxyuridine (dFdU) in plasma. [Period: From Day 0 to Day 32]

[0304] 8. Cmax, plasma dFdC (Arm 1). Analysis of the Cmax (maximum concentration reached over time) of gemcitabine (dideoxyfluorocytidine hydrochloride - dFdC) in plasma. [Period: From Day 0 to Day 32]

[0305] 9. Tmax, plasma dFdC (Arm 1). Analysis of the Tmax (day on which the maximum concentration was reached) of gemcitabine (dideoxyfluorocytidine hydrochloride - dFdC) in plasma [Period: From Day 0 to Day 32]

[0306] 10. Cavg, plasma dFdC (Arm 1). Analysis of descriptive statistics (such as sample size, mean and median, quartiles, minimum and maximum values, and box plots) of the concentration of gemcitabine (dideoxyfluorocytidine hydrochloride - dFdC) in plasma. [Period: From Day 0 to Day 32]

[0307] 11. Cmax, urine dFdU (Arm 1). Analysis of the Cmax (maximum concentration reached over time) of difluorodeoxyuridine (dFdU) in urine. [Period: From Day 0 to Day 32]

[0308] 12. Tmax, urine dFdU (Arm 1), Analysis of the Tmax (day on which the maximum concentration was reached) of difluorodeoxyuridine (dFdU) in urine [Period: From Day 0 to Day 32]

[0309] 13. Cavg, urine dFdU (Arm 1). Analysis of descriptive statistics (such as sample size, mean and median, quartiles, minimum and maximum values, and box plots) of the concentration of difluorodeoxyuridine (dFdU) in urine. [Period: From Day 0 to Day 32]

[0310] 14. Cmax, Urinary dFdC (Arm 1). Analysis of the Cmax (maximum concentration reached over time) of gemcitabine (difluorodeoxycytidine hydrochloride - dFdC) in urine. [Period: From Day 0 to Day 32]

[0311] 15. Tmax, Urinary dFdC (Arm 1). Analysis of the Tmax (day on which the maximum concentration was reached) of gemcitabine (difluorodeoxycytidine hydrochloride - dFdC) in urine. [Period: From Day 0 to Day 32]

[0312] 16. Cavg, Urinary dFdC (Arm 1). Analysis of descriptive statistics of the concentration of gemcitabine (difluorodeoxycytidine hydrochloride - dFdC) in urine (e.g., sample size, mean and median, quartiles, minimum and maximum values, and box plots) [Period: From Day 0 to Day 32]

[0313] 17. Preliminary antitumor effects are evaluated in tumor material (after treatment) for the evaluation of immunohistochemical tissue biomarkers of drug-induced cell death (AKT, CD31, Ki67, TUNEL). (Arm 1) [Period: Antitumor analysis is performed on Day 28, which is the next study day visit]

[0314] 18. Number of participants tolerable for TAR-200 indwelling (Arm 2) [Period: From Day 0 to Day 21]

[0315] 19. Percentage of participants tolerable for TAR-200 indwelling (Arm 2) [Period: From Day 0 to Day 21]

[0316] 20. Number of participants tolerable for TAR-200 indwelling (Arm 2) [Period: From Day 21 to Day 42]

[0317] 21. Percentage of participants tolerable for TAR-200 indwelling (Arm 2) [Period: From Day 21 to Day 42]

[0318] 22. Cmax, Plasma dFdU (Arm 2). Analysis of the Cmax (maximum concentration reached over time) of difluorodeoxyuridine (dFdU) in plasma. [Period: From Day 0 to Day 47]

[0319] 23. Tmax, Plasma dFdU (Arm 2). Analysis of the Tmax (day on which the maximum concentration was reached) of difluorodeoxyuridine (dFdU) in plasma. [Period: From Day 0 to Day 47]

[0320] 24. Cavg, Plasma dFdU (Arm 2). Analysis of the descriptive statistics (such as sample size, mean and median, quartiles, minimum and maximum values, and box plot) of the concentration of difluorodeoxyuridine (dFdU) in plasma. [Period: From Day 0 to Day 47]

[0321] 25. Cmax, Plasma dFdC (Arm 2). Analysis of the Cmax (maximum concentration reached over time) of gemcitabine (dideoxyfluorocytidine hydrochloride - dFdC) in plasma. [Period: From Day 0 to Day 47]

[0322] 26. Tmax, Plasma dFdC (Arm 2). Analysis of the Tmax (day on which the maximum concentration was reached) of gemcitabine (dideoxyfluorocytidine hydrochloride - dFdC) in plasma [Period: From Day 0 to Day 47]

[0323] 27. Cavg, Plasma dFdC (Arm 2). Analysis of the descriptive statistics (such as sample size, mean and median, quartiles, minimum and maximum values, and box plot) of the concentration of gemcitabine (dideoxyfluorocytidine hydrochloride - dFdC) in plasma.

[0324] 28. Cmax, Urine dFdU (Arm 2). Analysis of the Cmax (maximum concentration reached over time) of difluorodeoxyuridine (dFdU) in urine. [Period: From Day 0 to Day 47]

[0325] 29. Tmax, urinary dFdU (Arm 2). Analysis of the Tmax (day of reaching the maximum concentration) of difluorodeoxyuridine (dFdU) in urine [Period: from Day 0 to Day 47]

[0326] 30. Cavg, urinary dFdU (Arm 2). Analysis of descriptive statistics of the concentration of difluorodeoxyuridine (dFdU) in urine (e.g., sample size, mean and median, quartiles, minimum and maximum values, and box plot). [Period: from Day 0 to Day 47]

[0327] 31. Cmax, urinary dFdC (Arm 2). Analysis of the Cmax (maximum concentration reached over time) of gemcitabine (dideoxyfluorocytidine hydrochloride - dFdC) in urine. [Period: from Day 0 to Day 47]

[0328] 32. Tmax, urinary dFdC (Arm 2). Analysis of the Tmax (day of reaching the maximum concentration) of gemcitabine (dideoxyfluorocytidine hydrochloride - dFdC) in urine. [Period: from Day 0 to Day 47]

[0329] 33. Cavg, urinary dFdC (Arm 2). Analysis of descriptive statistics of the concentration of gemcitabine (dideoxyfluorocytidine hydrochloride - dFdC) in urine (e.g., sample size, mean and median, quartiles, minimum and maximum values, and box plot) [Period: from Day 0 to Day 47]

[0330] 34. The preliminary antitumor effect is evaluated in tumor materials (after treatment) for the evaluation of immunohistochemical tissue biomarkers of drug-induced cell death (AKT, CD31, Ki67, TUNEL). (Arm 2) [Period: The antitumor analysis is performed on Day 42, which is the next study day visit]

[0331] Inclusion criteria are: a histologically confirmed history of low or intermediate risk of urothelial carcinoma of the bladder, excluding in situ (pTis), pathologically staged pT1 (invasion into the lamina propria) carcinomas, and high-grade disease that is resectable (pT2 or greater) but not judged to be muscle-invasive. Appropriate test parameters. Urinalysis screening showing no clinically significant abnormalities, excluding those attributable to bladder cancer. No active treatment for a prior or concurrent neoplastic disease in the last three months and complete recovery from treatment effects. Patients receiving concurrent hormonal therapy for prostate cancer are permitted to enroll.

[0332] Exclusion criteria are: BCG therapy in the bladder and / or any other exposure. Chemotherapeutic agents within less than 1 year before registration excluding single postoperative instillation. Absence of visible tumors at the time of screening. Any prior exposure to intravesical gemcitabine instillation within the past 12 months. Presence of any anatomical features of the bladder or urethra that may interfere with the safe placement, indwelling use or removal of TAR-200 in the opinion of the investigator (i.e., bladder diverticulum, complete incontinence). Patients with recurrent high-grade urothelial cytology. Currently receiving other systemic or intravesical chemotherapy. Pelvic radiotherapy administered within 6 months before registration. Patients who received radiotherapy more than 6 months before registration should not show signs on cystoscopy or clinical symptoms of radiation cystitis. Post-void residual volume (PVR) of more than 250 mL. Active, uncontrolled genitourinary bacterial, viral or fungal infections including urinary tract infections. Cutaneous / nail fungal infections are not excluded. Subjects with active herpes zoster (varicella-zoster infection) are excluded from the study. History or presence of any serious cardiovascular, pulmonary, hepatic, renal, gastrointestinal, gynecological, endocrine, immunological, dermatological, neurological or psychiatric diseases or disorders that are contraindications to participation in the opinion of the investigator. Concomitant immunosuppressive drug therapy such as methotrexate or TNF inhibitors within 2 weeks of study Day 0 excluding steroids at a dose of 5 mg or less per day. Pregnant (confirmed by urine test at the time of screening) or lactating, or female subjects who are potentially fertile and not using an acceptable method of contraception. Presence of any condition (physical, mental or social) that may affect the subject's return for scheduled visits and follow-up observations, including refusal or inability to consent to informed consent or comply with the requirements of this protocol. Other unspecified reasons for which the patient is considered ineligible for registration in the opinion of the investigator or TARIS.

Table 2

Claims

**Claim 1** A pharmaceutical composition comprising gemcitabine for use in the treatment of urothelial carcinoma of the lower urinary tract in an individual, wherein the gemcitabine is delivered locally to the bladder, the urothelial carcinoma of the lower urinary tract is muscle-invasive bladder cancer, and the gemcitabine is delivered continuously to the bladder of the individual over 7 to 21 days. **Claim 2** The pharmaceutical composition according to claim 1, wherein the individual is not suitable for radical cystectomy. **Claim 3** The pharmaceutical composition according to claim 1 or 2, wherein the individual cannot tolerate systemic chemotherapy and / or chemotherapy with agents other than gemcitabine. **Claim 4** The pharmaceutical composition according to any one of claims 1 to 3, wherein the individual does not undergo radical cystectomy. **Claim 5** A pharmaceutical composition comprising gemcitabine for use in bladder preservation in an individual, wherein the gemcitabine is delivered continuously and locally to the bladder of the individual over 7 to 21 days, and the individual has muscle-invasive bladder cancer. **Claim 6** A pharmaceutical composition comprising gemcitabine for use in enhancing the immune response against urothelial carcinoma of the lower urinary tract in an individual, wherein the gemcitabine is delivered locally to the bladder, the urothelial carcinoma of the lower urinary tract is muscle-invasive bladder cancer, and the gemcitabine is delivered continuously to the bladder of the individual over 7 to 21 days. **Claim 7** The pharmaceutical composition according to any one of claims 1 to 6, wherein the gemcitabine is delivered continuously to the bladder of the individual over 7 days. **Claim 8** The pharmaceutical composition according to any one of claims 1 to 6, wherein the gemcitabine is delivered continuously to the bladder of the individual over 3 weeks. **Claim 9** The pharmaceutical composition according to any one of claims 1 to 6, wherein the continuous delivery of gemcitabine to the bladder over 7 to 21 days is the first gemcitabine delivery period. **Claim 10** The pharmaceutical composition according to claim 9, wherein the use further comprises a second gemcitabine delivery period, and the delivery period of the second gemcitabine is 7 to 21 days. **Claim 11** The pharmaceutical composition according to claim 10, wherein the first and second gemcitabine delivery periods are each 7 days. **Claim 12** The pharmaceutical composition according to claim 10, wherein the first and second gemcitabine delivery periods are each 3 weeks. **Claim 13** The pharmaceutical composition according to any one of claims 10 to 12, wherein the first and second gemcitabine delivery periods are separated by a 14-day drug-free period.

14. The pharmaceutical composition according to any one of claims 1 to 13, wherein gemcitabine is delivered at a first release rate at the first time of the delivery, followed by a second time of the delivery having a second release rate.

15. The pharmaceutical composition according to any one of claims 1 to 14, wherein gemcitabine is delivered at a dosage of about 1 mg / day to about 300 mg / day.

16. The pharmaceutical composition according to any one of claims 1 to 14, wherein gemcitabine is delivered at a dosage of about 5 mg / day to about 50 mg / day.

17. The pharmaceutical composition according to any one of claims 1 to 14, wherein gemcitabine is delivered at a dosage of about 10 mg / day to about 50 mg / day.

18. The pharmaceutical composition according to any one of claims 1 to 17, wherein the concentration of gemcitabine in urine is about 0.1 μg / mL to about 200 μg / mL during the delivery period.

19. The pharmaceutical composition according to claim 18, wherein the concentration of gemcitabine in urine is about 1 μg / mL to about 10 μg / mL during the delivery period.

20. The pharmaceutical composition according to claim 18, wherein the concentration of gemcitabine in urine is about 10 μg / mL during the delivery period.

21. The pharmaceutical composition according to any one of claims 1 to 20, wherein the gemcitabine concentration in the plasma of the individual is less than about 1 μg / ml.

22. The pharmaceutical composition according to any one of claims 1 to 21, wherein the ratio of gemcitabine in the urine of the individual to gemcitabine in the plasma is greater than about 500:1 during the delivery of gemcitabine.

23. The pharmaceutical composition according to any one of claims 1 to 22, which is delivered between the first gemcitabine delivery period and the second gemcitabine delivery period, wherein the concentration of gemcitabine in the urine of the individual is at least about 0.1 μg / mL, and there is a drug-free period between the first and second gemcitabine delivery periods.

24. The pharmaceutical composition according to claim 23, wherein the concentration of gemcitabine in urine is higher than about 1 μg / mL for at least half of the drug-free period.

25. The pharmaceutical composition according to any one of claims 1 to 24, which is characterized by being administered to the individual in combination with a second agent.

26. The pharmaceutical composition according to claim 25, wherein the second agent is delivered systemically.

27. The pharmaceutical composition according to claim 25, wherein the second agent is delivered locally.

28. The pharmaceutical composition according to claim 27, wherein gemcitabine and the second agent are delivered via a single delivery device.

29. The pharmaceutical composition according to any one of claims 25 to 28, wherein the second agent is an immunomodulatory agent.

30. The pharmaceutical composition according to claim 29, wherein the immunomodulatory agent is an immune checkpoint inhibitor.

31. The pharmaceutical composition according to claim 30, wherein the immune checkpoint inhibitor is an inhibitor of an immune checkpoint protein selected from the group consisting of PD-L1, CTLA4, PD-L2, PD-1, B7-H3, B7-H4, HVEM, B and T lymphocyte attenuator (BTLA), killer inhibitory receptor (KIR), GAL9, TIM3, A2AR, LAG-3, phosphatidylserine, CD27, TNF-α, CD33, Siglec-5, Siglec-7, Siglec-9 and Siglec-11.

32. The pharmaceutical composition according to claim 29, wherein the immunomodulatory agent is an agonist of a costimulatory immune molecule.

33. The pharmaceutical composition according to claim 32, wherein the costimulatory immune molecule is selected from the group consisting of CD40, OX40, ICOS, CD28, CD137 / 4-1BB, CD27, IL-10, TGF-beta, TOR receptor and glucocorticoid-induced TNF receptor-related protein GITR.

34. The pharmaceutical composition according to claim 29, wherein the second agent is an antibody that binds to PD-1.

35. The pharmaceutical composition according to any one of claims 25 to 28, wherein the second agent is a second chemotherapeutic agent.

36. The pharmaceutical composition according to claim 35, wherein the chemotherapeutic agent is selected from the group consisting of paclitaxel, docetaxel and oxaliplatin.

37. The pharmaceutical composition according to any one of claims 1 to 36, wherein the individual does not receive radiotherapy.

38. The pharmaceutical composition according to any one of claims 1 to 36, wherein the individual receives radiotherapy.

39. The pharmaceutical composition according to any one of claims 1 to 38, wherein gemcitabine is delivered in a neoadjuvant setting.

40. The pharmaceutical composition according to any one of claims 1 to 38, wherein gemcitabine is delivered in an adjuvant setting.

41. The pharmaceutical composition according to any one of claims 1 to 39, wherein the individual undergoes surgery and the delivery of gemcitabine to the individual is initiated at the time of the surgery.

42. The pharmaceutical composition according to any one of claims 1 to 41, wherein gemcitabine is delivered into the bladder by an intravesical device.

43. The pharmaceutical composition according to claim 42, wherein the intravesical device contains 100 mg to 500 mg of gemcitabine.

44. The pharmaceutical composition according to claim 43, wherein the intravesical device contains 225 mg of gemcitabine.

45. The pharmaceutical composition according to any one of claims 42 to 44, wherein the intravesical device includes a housing configured for intravesical insertion; and a dosage form containing gemcitabine, and the housing is configured to hold the dosage form and release gemcitabine in an amount effective for treating urothelial carcinoma of the lower urinary tract.

46. The intravesical device includes a housing that defines a reservoir; a first unit contained within the reservoir, the first unit containing gemcitabine; and a second unit contained within the reservoir at a position separate from the first unit, the second unit containing a functional agent that promotes the in vivo release of gemcitabine from the housing. The pharmaceutical composition according to any one of claims 42 to 45.

47. The pharmaceutical composition according to any one of claims 42 to 46, wherein the intravesical device contains gemcitabine, controllably releases it, and includes a housing that is elastically deformable between a retention shape configured to hold the intravesical device in the individual's bladder and a deployment shape for passage of the intravesical device through the individual's urethra.

48. The pharmaceutical composition according to any one of claims 42 to 47, wherein the intravesical device includes a drug reservoir lumen bounded by a first wall and a second wall, the first wall being impermeable to the drug, and the second wall being permeable to gemcitabine.

49. The pharmaceutical composition according to any one of claims 42 to 48, wherein the intravesical device comprises at least two drug reservoir lumens.

50. The pharmaceutical composition according to any one of claims 42 to 49, wherein gemcitabine is released from the intravesical device by osmotic pressure.

51. The pharmaceutical composition according to any one of claims 42 to 49, wherein gemcitabine is released from the device by diffusion.

52. The pharmaceutical composition according to any one of claims 42 to 51, wherein gemcitabine contained in the housing is in a non-liquid form.

53. The pharmaceutical composition according to claim 52, wherein the non-liquid form is selected from the group consisting of tablets, granules, powders, semi-solids, capsules and combinations thereof.

54. The pharmaceutical composition according to any one of claims 1 to 53, wherein about 225 mg of gemcitabine is delivered to an individual.

55. The pharmaceutical composition according to any one of claims 1 to 53, wherein about 200 mg to about 225 mg of gemcitabine is delivered to an individual.

56. The pharmaceutical composition according to any one of claims 1 to 55, wherein the bladder cancer is locally advanced bladder cancer or metastatic bladder cancer.

57. The pharmaceutical composition according to any one of claims 1 to 56, wherein gemcitabine is delivered to an individual at a dose of about 10 mg / day.

58. The pharmaceutical composition according to any one of claims 1 to 57, wherein the bladder cancer is BCG (Bacillus Calmette-Guérin) - refractory or BCG-resistant cancer or papillary bladder cancer.

59. The pharmaceutical composition according to any one of claims 1 to 58, wherein the individual is a human.

60. The pharmaceutical composition according to any one of claims 1 to 59, wherein the individual is unsuitable for systemic chemotherapy.

61. The pharmaceutical composition according to any one of claims 1 to 60, wherein the individual has a compromised immune system.

62. The pharmaceutical composition according to any one of claims 1 to 61, wherein the individual has a high level of immune checkpoint protein.

63. The pharmaceutical composition according to any one of claims 1 to 61, wherein the individual has a low level of immune checkpoint protein.

64. The pharmaceutical composition according to any one of claims 1 to 63, wherein the individual has a high level of nucleoside transporter.

65. The pharmaceutical composition according to any one of claims 1 to 63, wherein the individual has a low level of nucleoside transporter. **Claim 66** The pharmaceutical composition according to any one of claims 1 to 65, wherein the ratio of gemcitabine to metabolite in urine is determined, and a ratio below the threshold indicates an effective treatment.

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