BCG-naïve NMIBC: Optimizing initial treatment selection

In this video, recorded at the 2026 LUGPA Annual Meeting, Vignesh T. Packiam, MD, discusses the evolving role of BCG in high-risk, BCG-naïve non–muscle-invasive bladder cancer (NMIBC), including patient selection for combination treatment with immune checkpoint inhibitors. Packiam is an associate professor of surgery at Rutgers Robert Wood Johnson Medical School and director of clinical and translational research in urologic oncology at Rutgers Cancer Institute in New Jersey.

Packiam emphasizes that BCG will remain a central treatment option for high-risk NMIBC, particularly as recent studies have demonstrated improved outcomes when BCG is administered alongside appropriate transurethral resection of bladder tumor (TURBT) and effective staging. He notes that combination approaches may offer an opportunity to tailor treatment, particularly amid ongoing BCG shortages. However, clinicians should carefully consider which patients are most likely to benefit from adding systemic immunotherapy to BCG.

Discussing patient selection, Packiam highlights subgroup findings suggesting that patients with T1 disease, carcinoma in situ, or younger age may derive greater benefit from adding an immune checkpoint inhibitor to BCG. He also stresses the importance of balancing this potential benefit against additional toxicity and adverse effects. For patients who prioritize further recurrence reduction and are willing to accept the possibility of added toxicity, combination treatment may be a reasonable consideration.

When selecting initial treatment, Packiam underscores the need to evaluate recurrence and progression risks, the potential for cystectomy, and individual patient preferences. He notes that maintenance BCG can help keep recurrence and progression risks relatively low, making shared decision-making particularly important when considering treatment intensification.

As he explains, “We just have to think carefully about who's the best patient to receive the treatment.”