Bacille Calmette–Guérin dosage; challenging dogmas and changing paradigms

Peer review under responsibility of Arab Association of Urology.

A ‘dogma’ is defined as a belief that is proposed by authority figures to be ‘true’ even though no or marginal data exist to support the belief.

Since Morales proposed the original BCG protocol against bladder cancer in 1972, several dogmas still exist to date with its use. Morales chose a 6-weekly treatment regimen just for the convenience, as the utilised strain was provided by the Institute Armand Frappier in packages of six vials! A dose of 120 mg was also chosen based on previous humble animal studies. Morales also postulated that side-effects should last less than a week, thus, weekly instillation was described.

Four decades later, many BCG dogmas are yet to be questioned. What is the best clinical schedule? Best dosage? Best strain? And several other questions remain unanswered.

In this issue of the Arab Journal of Urology, two articles by Kandeel et al. [1] and Nour et al. [2], continue this line of research and question the ideal BCG dose. This approach has gained popularity in light of the recent shortages of BCG supply worldwide.

Both studies suggest that full-dose BCG may not be necessary in all patients and that lowering the dose to one-half or one-third may be equally effective with a reduction in the associated side-effects. Although, some concerns exist in the literature about dose reduction in high-risk patients, the data available remain inconclusive. At this time, it is important to overcome prejudices, and embrace changes and modifications in dose regimens of BCG, which remains the most effective local therapy for non-muscle-invasive bladder cancer and the most successful application of immunotherapy in our field.

Conflicts of interest

None declared.

Notes

Peer review under responsibility of Arab Association of Urology.