BCG Induction and Maintenance Schedule for Bladder Cancer

Standard Induction Schedule

The American Urological Association recommends BCG induction consisting of weekly intravesical instillations for 6 consecutive weeks, initiated at least 2 weeks after transurethral resection or bladder biopsy, using one full vial of BCG (TICE® 50 mg or Theracys® 81 mg) suspended in 50 mL preservative-free saline 1, 2, 3
Never administer BCG within 24 hours of bladder tumor resection—this can be dangerous due to systemic absorption risk 1, 3
Allow 4-6 weeks rest period after completing induction before performing re-evaluation cystoscopy 4

The European Association of Urology recommends maintenance BCG using the SWOG schedule, which consists of 3 weekly instillations at months 3, 6, 12, 18, 24, 30, and 36 after the start of induction for high-risk patients 1, 2, 3
For intermediate-risk patients, the National Comprehensive Cancer Network recommends maintenance therapy for at least 1 year (maintenance cycles at months 3, 6, and 12 only) 1, 2, 3
The EORTC 98013 trial suggests 1 year of SWOG maintenance is sufficient for intermediate-risk patients 1

The American Urological Association recommends all high-risk patients receive full 3-year maintenance therapy (total of 7 maintenance cycles at the timepoints listed above), which significantly reduces recurrence compared to 1-year maintenance (HR 1.61, 95% CI 1.13-2.30, P = 0.01) 1, 2, 3
Level A evidence supports this recommendation for high-risk patients 1, 3

BCG must be initiated at least 2 weeks after TURBT or biopsy, and ideally 2-4 weeks, to avoid systemic absorption 1, 3
Never instill BCG in the presence of gross hematuria or active urinary tract infection—this can cause systemic BCG toxicity 1, 3

Full-dose BCG should be used for both induction and maintenance therapy 1, 3
Dose reduction during maintenance may be necessary if side effects occur, using serial reductions to one-third, one-tenth, one-thirtieth, or one-hundredth of the standard dose 1, 3
The Oddens trial demonstrated efficacy hierarchy: full dose for 3 years > one-third dose for 3 years > full dose for 1 year > one-third dose for 1 year 1, 3

Do not use modified maintenance schedules (monthly single instillations, quarterly schedules)—these lack efficacy data 1, 6
Do not skip maintenance therapy—this is where much of the benefit for preventing progression occurs 1, 4, 8
Do not give only 1 year of maintenance to high-risk patients—3 years is required for optimal outcomes 1, 2