Maintenance Bacillus Calmette-Guérin: The Standard of Care for the Prophylaxis and Management of Intermediate- and High-Risk Non–Muscle-Invasive Bladder Cancer

ContextAlthough bacillus Calmette-Guérin (BCG) is currently regarded as the most effective treatment available for the management of non–muscle-invasive bladder cancer (NMIBC), maintenance BCG is underutilised and debate still remains as to whether the routine use of maintenance therapy is required for optimal outcomes.ObjectiveTo review evidence supporting the need for maintenance BCG and provide practical strategies for improving both patient and physician compliance with maintenance regimens.Evidence acquisitionData from immunologic studies, animal studies, randomised clinical trials, and meta-analyses were reviewed during a satellite symposium at the 25th Annual European Association of Urology (EAU) Congress, held in Barcelona, Spain, in April 2010.Evidence synthesisThree well-designed, long-term clinical trials and various meta-analyses have shown maintenance BCG to be significantly superior to intravesical chemotherapy and induction therapy alone in reducing recurrence, progression, and mortality in patients with intermediate- and high-risk NMIBC. Despite these findings, BCG therapy is underutilised. Experts have questioned whether this is solely due to BCG-associated adverse events or whether other patient- and physician-related factors, such as lack of patient knowledge and physician attitudes, may affect utilisation and adherence to BCG therapy.ConclusionsRecent evidence has addressed controversies surrounding the use of maintenance BCG. Maintenance BCG should now be considered the “gold standard” therapy for the prophylaxis and management of intermediate- and high-risk NMIBC. Although BCG-associated adverse events are generally considered to be the primary reason for poor adherence, these adverse events can be prevented and successfully managed in most patients. Furthermore, other patient- and physician-related factors need to be addressed to help promote adherence to maintenance BCG and optimise outcomes in patients with NMIBC.