Bacillus Calmette-Guérin Therapy: Optimizing Outcomes amid Challenges.

Bacillus Calmette-Guérin (BCG) remains the cornerstone adjuvant therapy for intermediate-risk and high-risk non--muscle invasive bladder cancer, yet its clinical utility is increasingly challenged by supply shortages, treatment intolerance, and variable oncologic response. This article summarizes the immunologic basis, efficacy, and limitations of BCG, examines evidence for alternative administration strategies, evaluates combination and biomarker-based approaches to optimize patient selection, and outlines emerging therapies for BCG-unresponsive disease. Practical, evidence-driven recommendations are provided to guide contemporary management during periods of constrained supply and evolving therapeutic landscapes.