Is BCG Better Than We Thought? Reassessing Its Role Through Modern Evidence

Intravesical bacillus Calmette-Guérin (BCG) remains the cornerstone of treatment for high-risk non–muscle-invasive bladder cancer (NMIBC). Despite decades of use and consistent endorsement in international guidelines, the true magnitude of its benefit in contemporary practice remains incompletely defined. Much of the historical evidence supporting BCG was generated in heterogeneous patient populations, with variable maintenance schedules, inconsistent definitions of BCG adequacy, and limited long-term, risk-stratified outcome reporting.Recent evidence has renewed interest in the role of BCG as more than a historical standard. Modern randomized trials such as ALBAN, CREST, and POTOMAC have repositioned BCG as the therapeutic backbone against which novel strategies, including checkpoint inhibitor combinations, are being evaluated. Notably, across these studies, outcomes in the BCG-alone arms were more favorable than many clinicians may have expected, with relatively low rates of progression and more durable disease control than previously reported. These findings raise important questions about whether the efficacy of adequately delivered BCG has been historically underestimated, and to what extent contemporary outcomes may reflect improved patient selection, higher-quality resection, better adherence to maintenance schedules, and more standardized follow-up.These developments have shifted the clinical question. The issue is no longer simply whether BCG works, but rather how well it performs when optimally delivered, in which patients it remains the preferred treatment, how BCG failure should be interpreted, and when treatment intensification or early escalation is justified. This Research Topic aims to collect contemporary real-world evidence on BCG outcomes in order to better define its effectiveness in routine practice and determine whether results achieved outside clinical trials are comparable to those reported in modern prospective studies.This Research Topic aims to critically reassess the role of BCG in the modern management of high-risk NMIBC. We seek to bring together contemporary evidence defining the real-world efficacy of adequate BCG, clarifying the prognostic implications of different BCG failure patterns, and contextualizing BCG within the rapidly evolving landscape of bladder-sparing strategies, checkpoint inhibitor combinations, and biomarker-driven approaches.The objective is not only to re-evaluate BCG outcomes, but also to better define its therapeutic boundaries: which patients derive durable benefit from BCG alone, which patients may require early escalation, and how modern clinical and translational evidence can refine treatment selection.This Research Topic welcomes contributions from investigators and centers with expertise in NMIBC and intravesical therapy. We are particularly interested in studies that provide clinically meaningful, contemporary insight into the effectiveness, limitations, and evolving role of BCG in high-risk disease.We encourage submission of Original Research, Systematic Reviews, Mini Reviews, Perspectives, and well-designed multicenter or prospective cohort studies addressing topics including, but not limited to:- contemporary oncologic outcomes with adequate versus inadequate BCG;- real-world efficacy in high-risk and very-high-risk NMIBC;- BCG failure patterns and their prognostic implications;- checkpoint inhibitor combinations in BCG-naïve disease;- patient selection factors; risk stratification and follow-up optimization;- biomarkers and liquid biopsy;- quality of life;- and comparative analyses of BCG schedules and maintenance strategies. Topic editors: Pietro Scilipoti, Aleksander Ślusarczyk, Salvatore Siracusano Source: https://www.frontiersin.org/research-topics/80368/is-bcg-better-than-we-thought-reassessing-its-role-through-modern-evidence