How do you approach immunosuppression in patients with a positive Interferon Gamma Release Assay and prior intravesicular BCG treatment for bladder cancer?

Bacillus Calmette–Guérin (BCG) is the most widely used vaccine worldwide and has been used to prevent tuberculosis for a century. BCG also stimulates an anti-tumor immune response, which urologists have harnessed for the treatment of non-muscle-invasive bladder cancer.

As rheumatologists, we occasionally see patients who have been treated with BCG who require immune suppressive therapy for their rheumatologic disease or who have already been treated with a TNFi drug and now require BCG therapy.

Since TNF is a critical component of our body's defense against mycobacterial infection, the use of TNFi in someone who has received intravesicular BCG can be hazardous. In fact, oncologists recommend that recent use (<12 months) use of TNFi as an a...