BCG update: intravesical therapy

BCG is currently the most active immunotherapy agent for intravesical use and is considered the first-line treatment for patients with aggressive T1 G3 and Tis superficial tumors of the bladder. Its main drawback, toxicity, is being addressed by several prospective studies that try to find the lowest active dose and optimal schedule, as well as by studies investigating the efficacy of antigenic bacterial fractions, devoid of the toxicity of the living bacilli. Efforts to improve the efficacy by combination with chemotherapy and biomodulating natural remedies are also under way. In this review we discuss: (1) the indications, limits and contraindications of BCG; (2) the efficacy; (3) the strains; (4) route of administration; (5) dose; (6) schedule; (7) the problem of toxicity, and (8) how to improve BCG therapy.