Purpose: In the fall of 2014, the New Mexico VA Healthcare System received notification that there was a national short-age of Bacillus Calmette-Guerin (BCG). This shortage of BCG had serious implications for patients with bladder cancer and for the cancer programs providing their care. Many patient treatments were interrupted due to lack of supply of BCG. A triage algorithm was required to determine which patients should receive treatment with this limited resource, and there was a need to develop a reliable tracking system to monitorpatients who were receiving BCG.
Methods: A process improvement plan was developed by a multidisciplinary team that included the chief of urology, urology nurse manager, urology cancer care coordinator (CCC), pharmacy, and the hospital ethics department. Pharmacy created a report that identified all patients who received BCG in 2014. The CCC used this report to develop a spreadsheet identifying the patient, pathology, and treatment history. The urologist reviewed pathology reports of 48 patients for high-, intermediate-, and low-grade bladder cancer, and a treatment algorithm for BCG was developed.
Results: Eighteen patients with the highest priority for BCG were those patients with higher risk of progression (to muscle invasive disease), such as patients with carcinoma in situ or high-grade (hg) disease. Five of those patients had their treatment delayed or interrupted due to the BCG shortage; 1 patient was fee based for treatment, 1 patient moved out of state, 1 patient refused treatment, and 1 patient had a cystectomy. Five patients considered at intermediate risk (Ta hg) were triaged to an alternative treatment group who received gemcitabine. Twenty-five patients with recurrent Ta low grade (lg) or multifocal Ta lg bladder cancer were triaged tosurveillance cystoscopies or mitomycin.
Conclusions: Despite limited availability of BCG, a treatment algorithm was developed, and alternate therapies were identified to treat patients with bladder cancer. An effective monitoring system to track patients prevented delays in therapy that could result in serious consequences. The algorithm and tracking mechanism proved to be effective in managing this cancer population and can be used as a model for other cancer programs with BCG shortages
