The Efficacy of a Second BCG Induction Course for Non-Muscle Invasive Bladder Cancer - Expert Commentary

The American Urological Association (AUA) recommends that non-muscle invasive bladder cancer (NMIBC) patients with persistent or recurrent Ta or CIS should receive a second induction course of Bacillus Calmette-Guerin (BCG) after the first course. However, a significant number of patients decline. Real-world data evaluating the efficacy of a second BCG induction course is needed.

A recent article published by Daniels et al. in Urologic Oncology assessed the impact of the second BCG course on clinical outcomes in NMIBC patients. In this multi-institutional study, the investigators included 353 patients diagnosed with NMIBC between 2011 and 2018. All patients received six weeks of induction BCG therapy (BCG1 group); of these, 116 patients received a second course of BCG (BCG2 group).
The authors also found that T1 stage before starting treatment is more common in the BCG1 group with 40.8% vs. 25% in the BCGC2 group while CIS before treatment is more common in the BCGC2 group with 33.6% vs. 13.9% in the BCGC1 group (P < 0.001). 117 (33.1%) patients received maintenance therapy after BCG1, and 43 (37.1%) patients received maintenance therapy after BCG2.

The investigators identified complete responses in 276 patients (78.2%) at three months and 193 (54.7%) at 36 months in BCG1. A complete response was achieved in 104 patients (89.7%) at three months and 76 (65.6%) at 36 months in BCG2. Five (1.42%) patients progressed to muscle-invasive bladder cancer (MIBC) after receiving BCG1 and four (3.45%) patients after receiving BCG2 (P = 0.17). Neither progression to MIBC (p = 0.21) nor recurrence (p = 0.87) were predicted by pathologic stage before BCG2. Response to BCG2 was not associated with the duration between BCG1 and BCG2.

This data supports the efficacy of a second induction course of BCG as recommended by the AUA. Addressing BCG shortages and generating additional real-world efficacy data are critical for optimal utilization.

Written by: Bishoy M. Faltas, MD, Director of Bladder Cancer Research, Englander Institute for Precision Medicine, Weill Cornell Medicine, New York City, New York


1. Daniels, Marcus J., Emily Barry, Mark Schoenberg, Donald L. Lamm, Trinity J. Bivalacqua, Alex Sankin, and Max Kates. "Contemporary oncologic outcomes of second induction course BCG in patients with nonmuscle invasive bladder cancer." In Urologic Oncology: Seminars and Original Investigations. Elsevier, 2019.

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