Alternative Therapies to Bacillus Calmette-Guérin Shortage for Nonmuscle Invasive Bladder Cancer in Brazil and Other Underdeveloped Countries: Management Considerations

Abstract

Bacillus Calmette-Guérin (BCG) plays a cornerstone role in the management of nonmuscle invasive urothelial carcinoma of the bladder. However, there has been a worldwide intermittent BCG shortage in recent years that may affect the care of patients with bladder cancer and pose difficult clinical decisions to urologists and clinical oncologists. This literature review aims to clarify alternatives to BCG during a shortage and propose measures to replace BCG, mainly in Brazil and probably in other low- and middle-income countries, where not all studied and commonly suggested treatments are available.

Impact of the COVID-19 Pandemic on the Urologist’s clinical practice in Brazil: a management guideline proposal for low- and middle-income countries during the crisis period

“…In selected cases we can consider postpone one dose during the maintenance. In the case of BCG shortage supply, gemcitabine can be used (16,17).…”

Partial Versus Complete Bacillus Calmette-Guérin Intravesical Therapy and Bladder Cancer Outcomes in High-risk Non–muscle-invasive Bladder Cancer: Is NIMBUS the Full Story?

“…Guidelines recommend a 6-wk induction course of adjuvant BCG followed by maintenance for 3 yr for patients with BCG-responsive disease [2] , [7] . Unfortunately, repetitive global shortages have disrupted guideline-recommended BCG therapy for many high-risk patients [8] , [9] . BCG instillations have been rationed and diluted in an attempt to treat the greatest number of patients [8] , [9] .…”

“…Unfortunately, repetitive global shortages have disrupted guideline-recommended BCG therapy for many high-risk patients [8] , [9] . BCG instillations have been rationed and diluted in an attempt to treat the greatest number of patients [8] , [9] . However, the European Association of Urology (EAU) Research Foundation’s NIMBUS trial indicates that reducing BCG induction to three doses at 1, 2, and 6 wk is inferior to standard 6-wk induction [10] .…”

Non-maintenance intravesical Bacillus Calmette–Guérin induction therapy with eight doses in patients with high- or highest-risk non-muscle invasive bladder cancer: a retrospective non-randomized comparative study

“…However, NMIBC management currently faces a chronic dearth of BCG [ 9 , 20 , 21 ]. Appropriate management of bladder cancer is a serious issue in low-income countries, which cannot afford to import enough supply of BCG [ 22 ]. There is an urgent need to re-optimize the use of scarce BCG vials.…”