For muscle-invasive bladder cancer patients achieving a complete response to neoadjuvant therapy, a barrier to forgoing bladder removal is local relapse risk. Adding intravesical BCG could prevent these recurrences, making bladder preservation a more viable long-term strategy for these patients.
The Sac o six nineteen trial showed compelling results adding BCG to a chemo-immunotherapy backbone. However, the standard of care has already shifted to a newer combination (enfortumab vedotin and pembrolizumab), making it difficult to translate the study's findings into current practice and complicating the design of future trials.
By improving response rates before surgery, adding intravesical BCG can reduce the number of patients requiring follow-up adjuvant systemic therapy. This de-escalation strategy limits patients' overall exposure to toxic treatments and their side effects, a key benefit beyond improving primary outcomes.