Optimizing BCG therapy.

Bacillus Calmette-Guerin (BCG) is still the most appropriate primary therapy for high-risk patients and appropriate primary or secondary therapy for patients with intermediate-risk disease. The highest disease-free rates will be found in patients who are BCG naïve, have low tumor burden, are stage Ta or CIS, and those relatively younger (<80 years). Repeat transurethral resection (TUR) for stage T1 disease, BCG maintenance, and dose/regimen alterations are likely to improve efficacy and/or tolerability. There is potential utility for antifibrinolytic drugs, cytokine supplementation (IL2/IFN), and Cox-2 inhibitors. BCG failures continue to present unique challenges with a relatively narrow window of safety for repeat BCG use. Those who fail BCG repeatedly early are at an especially high risk for progression and should be offered expedient curative cystectomy whenever feasible. While not without risk, certain select patients may still be appropriate for alternative conservative therapy.