Do Toxicities to Intravesical BCG different in India and can it change the Dosage Schedule
We have been recently hearing a lot regarding BCG shortage and alternative Treatments to be considered. We are also hearing considerably regarding BCG Unresponsive NMIBC and alternate treatments for the same.
I am providing an article by Sam S Chang*et al (2020 available online from Nov10th) on ‘Side Effects of Intravesical BCG and Chemotherapy for Bladder Cancer: What They Are and How to manage them’. The article is worth reading and understanding.
Most of what has come out on these aspects are from Western Literature and do they equate to Indian scenario. How often do we see Grade 3 and 4 toxicities associated with Intravesical BCG? Most often we see grade 1 and occasionally Grade 2 toxicities. Does this mean that the responses to BCG are different in Indians when compared to Western Countries? There are few articles addressing this issue from Oriental Countries though TB is common even now in these countries and as per the WHO report India has the highest incidence of TB. There are studies from India, especially Madhu Agrawal and few others that a reduced dose of 80mg is as effective as 120 mg and this reduces the associated toxicities. There are some studies which mention that even 40mg can be as effective (CUETO study). Prof. C Chinnaswamy has opined that he has never used more than 40mg/dose and have never regretted (personal communication).
An article addressing this issue as to Intravesical BCG usage in India (South Indian Population) has been brought out by Ginil Kumar et al in 2019. They have addressed this aspect in detail and have opined that ‘maintenance therapy does not enhance the therapeutic effects of BCG in patients who respond favourably to 6 weeks of induction. He opines that most born after 1948 in India did receive BCG as a vaccine for TB and the inherent Immunity developed could be a reason for the difference.
This is an aspect that we have to consider when dealing with NMIBC as this appear more common in India than even P ca though we talk about P Ca more than B Ca.
With warm regards,