Immunotherapy for Bladder Cancer: What to Expect in the UK 

Immunotherapy treats bladder cancer by helping your immune system recognise and attack cancer cells. Unlike chemotherapy, which directly kills rapidly dividing cells, immunotherapy takes the brakes off immune cells or stimulates them locally in the bladder. In the UK this often means BCG for early, non‑muscle‑invasive disease, and checkpoint inhibitors for more advanced or high‑risk cancer.

This guide explains who immunotherapy is for, how it works, and the pros and cons of each option. We’ll cover BCG and checkpoint inhibitors, when they’re used with surgery, chemotherapy or radiotherapy, the tests that guide eligibility, what treatment and monitoring involve, benefits and side effects, NHS and private access, costs, support, and the latest UK updates.

Who immunotherapy is for in bladder cancer

Immunotherapy for bladder cancer is used for high‑risk non‑muscle‑invasive disease (intravesical BCG); for inoperable locally advanced or metastatic cancer (checkpoint inhibitors), including avelumab maintenance after platinum chemotherapy if disease hasn’t progressed; and after cystectomy in high‑risk cases (adjuvant nivolumab when chemotherapy isn’t suitable and PD‑L1 is high).

How immunotherapy works

Immunotherapy boosts your body’s own defences against urothelial cancer. In advanced disease, checkpoint inhibitors block PD‑1/PD‑L1 signals that switch off T cells, re‑energising them to recognise and kill cancer cells. For early disease, intravesical BCG triggers a focused immune reaction in the bladder lining to clear residual tumour cells and reduce recurrence.

Types of immunotherapy used

Two main types are used in the UK. For high‑risk non‑muscle‑invasive disease, intravesical BCG stimulates a local immune response. For muscle‑invasive, locally advanced or metastatic cancer, systemic checkpoint inhibitors (avelumab, atezolizumab, nivolumab, and in Scotland pembrolizumab) block PD‑1/PD‑L1 to help T cells attack cancer.

BCG for non‑muscle‑invasive bladder cancer

Immunotherapy for bladder cancer at high‑risk early stages often means BCG (Bacillus Calmette‑Guérin). It is placed directly into the bladder (intravesical) to trigger a local immune response that reduces recurrence and progression. Around 70% of patients go into remission after BCG therapy.

BCG is given as an outpatient treatment through a small catheter; you usually go home the same day. It’s delivered in a planned series of instillations, sometimes with maintenance courses. Common effects include temporary bladder irritation and mild, flu‑like symptoms. Your team will explain what to watch for and when to call.

Checkpoint inhibitors for advanced bladder cancer

When bladder cancer has spread or is not operable, checkpoint inhibitors are the main form of immunotherapy for bladder cancer used across the UK. These drugs block PD‑1/PD‑L1 signals that switch off T cells, and can be given as first‑line treatment if chemotherapy isn’t suitable (often depending on PD‑L1 levels), as maintenance after chemotherapy, or as second‑line therapy if cancer has previously been treated with chemotherapy. Treatment is an intravenous infusion in the day unit, typically every few weeks.

• Avelumab (Bavencio): used as maintenance after platinum chemotherapy when disease has not progressed; available across England, Wales, Scotland and Northern Ireland.
• Atezolizumab (Tecentriq): in England, Wales and Northern Ireland, can be used first‑line if chemotherapy isn’t suitable and PD‑L1 is high, or second‑line after chemotherapy; not recommended for bladder cancer by the SMC in Scotland.
• Pembrolizumab (Keytruda): recommended by the SMC in Scotland after chemotherapy for locally advanced or metastatic disease; not approved by NICE for bladder cancer in England, Wales or Northern Ireland.

Your team may test the tumour for PD‑L1 to guide eligibility, and will advise whether a checkpoint inhibitor is appropriate in your treatment plan. (Nivolumab is used in the UK primarily as adjuvant therapy after cystectomy in high‑risk cases.)

Combination therapies and latest UK updates

Combination and sequencing are reshaping care. After platinum chemotherapy, avelumab maintenance is standard across the UK. Antibody–drug conjugates such as enfortumab vedotin are used in advanced disease, and in 2025 NHS England announced a new two‑pronged regimen pairing enfortumab vedotin with immunotherapy, reporting markedly improved survival. Other chemo‑radiotherapy or dual‑immunotherapy combinations remain mainly available via clinical trials.

When immunotherapy is used in your treatment pathway

For high‑risk non‑muscle‑invasive bladder cancer, immunotherapy usually follows tumour removal (TURBT). BCG is instilled into the bladder as an induction course with planned maintenance to lower recurrence and progression risk.

For muscle‑invasive disease treated with bladder removal, adjuvant nivolumab may be offered if you’re at high risk of recurrence, chemotherapy isn’t suitable and the tumour shows high PD‑L1. In inoperable locally advanced or metastatic cancer, you may have a checkpoint inhibitor straight after platinum chemotherapy as maintenance (avelumab if the cancer hasn’t progressed), as first‑line treatment when chemotherapy isn’t suitable and PD‑L1 is high, or as second‑line therapy after chemotherapy (including pembrolizumab in Scotland).

Tests and biomarkers that guide eligibility

Before starting immunotherapy for bladder cancer, your team will review tissue from your tumour to check biomarkers that predict benefit. The most used is PD‑L1, measured on cancer cells by immunohistochemistry. Pathologists can often test archived tissue from a prior biopsy or operation; occasionally a second biopsy is needed. Alongside this, doctors consider your stage, prior chemotherapy, overall fitness and kidney function to decide if a checkpoint inhibitor or BCG is appropriate.

• PD‑L1 required in some settings: first‑line atezolizumab if chemotherapy isn’t suitable; adjuvant nivolumab after cystectomy in selected high‑risk cases when chemotherapy isn’t suitable.
• PD‑L1 not required: avelumab maintenance after platinum chemotherapy when disease hasn’t progressed; atezolizumab second‑line after chemotherapy; pembrolizumab after chemotherapy in Scotland.
• How testing happens: PD‑L1 is done on tumour tissue (from TURBT, biopsy or surgery); your team will advise if fresh sampling is needed.

How treatment is given and monitored

BCG is given directly into the bladder through a small catheter in the outpatient clinic; you go home the same day. Checkpoint inhibitors are intravenous infusions in the day unit every few weeks, delivered via a cannula or, if needed, a temporary central line. Treatment runs in cycles with planned rest periods, and monitoring continues throughout and after therapy because immune‑related effects can appear weeks or months later.

• Regular tests: bloods to check blood count, kidneys, liver and hormones.
• Response checks: periodic scans to assess how well treatment is working.
• During BCG: urine tests and symptom reviews at clinic visits.
• Safety: carry your treatment alert card and report new symptoms promptly.

Benefits and effectiveness you can expect

Effectiveness depends on stage and the specific immunotherapy. For high‑risk non‑muscle‑invasive disease, BCG lowers the chances of cancer coming back or progressing; around 70% of patients go into remission after BCG. In advanced disease, checkpoint inhibitors can help keep cancer under control and may lead to durable benefit in some people. After bladder removal, adjuvant nivolumab can lower the risk of recurrence in carefully selected high‑risk cases.

• BCG (intravesical): reduces recurrence/progression; remission in about 70% of patients.
• Checkpoint inhibitors: can control advanced cancer when chemotherapy isn’t suitable, as maintenance after chemotherapy, or after chemotherapy if it returns.
• Adjuvant nivolumab: may reduce recurrence risk after cystectomy in high‑risk, PD‑L1‑positive cases when chemotherapy isn’t suitable.

Side effects and safety: common, serious and late effects

Immunotherapy is generally well‑tolerated, but side effects can be unpredictable and sometimes serious. They may start during treatment or weeks to months later (occasionally more than a year after finishing). Tell your team promptly about any new symptoms, and carry the treatment alert card you’re given so other clinicians know you’re on immunotherapy.

• Checkpoint inhibitors – common: tiredness, mild skin rash/itch, diarrhoea, reduced appetite, cough or mild breathlessness, flu‑like symptoms, and infusion reactions (fever, chills, headache). Hormone (endocrine) changes can occur and will be checked in blood tests.

• BCG – common: bladder irritation (burning when passing urine, urgency/frequency), mild bleeding, low‑grade fever and flu‑like symptoms for 24–48 hours.

• Urgent symptoms to report: worsening diarrhoea or tummy pain (possible colitis), increasing breathlessness or new cough (pneumonitis), yellowing of eyes/skin or dark urine (hepatitis), severe or spreading rash, severe headache or confusion, or extreme fatigue, dizziness or weight change (possible hormone gland inflammation).

• Late effects: some immune‑related problems can appear or persist after treatment ends, including skin, gut, lung, liver or hormone issues. Ongoing monitoring with blood tests and scans helps detect and treat these early.

Who may not be suitable and how risks are managed

Immunotherapy isn’t right for everyone. It may be avoided if you have an active infection, autoimmune disease needing immunosuppression, or if eligibility criteria (for example PD‑L1 requirements in some settings) aren’t met. Risks are managed with pre‑treatment checks, regular bloods and scans, early symptom reporting, and prompt steroids for immune‑related effects.

Combining immunotherapy with surgery, chemotherapy or radiotherapy

Immunotherapy is often paired with standard care. For high‑risk NMIBC, BCG follows TURBT to reduce recurrence. In advanced disease, avelumab maintenance follows platinum chemotherapy if cancer hasn’t progressed. After cystectomy, selected high‑risk, PD‑L1‑positive patients may receive adjuvant nivolumab. Trials are exploring checkpoint inhibitors with chemoradiotherapy and with enfortumab vedotin.

Access and availability on the NHS and privately in the UK

Access to immunotherapy for bladder cancer is agreed nationally (NICE in England, AWMSG in Wales, SMC in Scotland; Northern Ireland usually follows NICE) and delivered via your hospital’s multidisciplinary team. Eligibility depends on stage, prior chemotherapy and PD‑L1 testing. Private care can often offer faster appointments, organise biomarker testing promptly, and deliver the licensed, guideline‑approved options while coordinating insurer authorisations. NHS England has also announced a 2025 rollout of a new regimen combining enfortumab vedotin with an immunotherapy in advanced disease.

• Avelumab maintenance: UK‑wide after platinum chemotherapy if disease has not progressed.
• Atezolizumab: England/Wales/NI first‑line if chemo isn’t suitable and PD‑L1 is high, or second‑line after chemo; not available in Scotland.
• Nivolumab (adjuvant): UK‑wide after cystectomy in selected high‑risk cases when chemo isn’t suitable and PD‑L1 is high.
• Pembrolizumab: SMC‑approved in Scotland after chemotherapy; not NICE‑approved for bladder cancer in England/Wales/NI.

Costs, insurance and practical support

On the NHS, immunotherapy for bladder cancer is funded when approved and you’re eligible; hospital‑delivered drugs and infusions are free at the point of use. Privately, insurers usually cover licensed/NICE‑approved regimens with pre‑authorisation; self‑pay is possible but costly. Your team can also signpost travel‑cost schemes, parking concessions and charity benefits advice.

Living well during and after treatment

During immunotherapy for bladder cancer, pace your day and keep active with gentle walks to combat fatigue. Stay hydrated, eat when you can, and keep a symptom diary. Carry your treatment alert card and report new symptoms promptly. Emotional support from family, peers or specialist nurses helps.

Questions to ask your urology and oncology team

Which stage is my cancer and what is the goal of treatment? Am I eligible for BCG or a checkpoint inhibitor and do I need PD‑L1 testing? What benefit is realistic, how will we monitor it, key side effects and red flags, who to contact, access (NHS/private), and trial options?

Trusted resources and clinical trials

For trustworthy UK information and clinical trials, use NHS‑aligned sources and speak to your MDT. They cover immunotherapy for bladder cancer, helplines and ways to join studies.

• Cancer Research UK: information, trial search, Cancer Chat, nurse 0808 800 4040.
• Macmillan Cancer Support: information, trial guidance, Support Line 0808 808 00 00.

Next steps

You now have a clear picture of who benefits from immunotherapy, how it’s given, and when it fits into bladder cancer care. The next step is a focused discussion about your eligibility, PD‑L1 testing, timing with surgery or chemotherapy, and NHS versus private access. For timely, personalised guidance or a second opinion, you can book a private consultation with Mr Ashwin Sridhar to plan the safest, most effective route for you.