Transcript of Pioneering Progress in BCG Treatments: An Interview with Dr. Donald LammTranscript of

April 2, 2024

Click here to listen to the podcast

Rick Bangs:

Hi, I’m Rick Bangs, the host of Bladder Cancer Matters, a podcast for, by and about the bladder cancer community. I’m also a survivor of muscle-invasive bladder cancer, the proud owner of a 2006 mile-a-year neobladder, and a patient advocate supporting cancer research at the Bladder Cancer Advocacy Network, or as many call it BCAN, producers of this podcast.

I’m pleased to welcome today’s guest, Dr. Don Lamm. Dr. Lamm is president of BCG Oncology in Phoenix, Arizona, and former professor of urology at the Mayo Clinic in Scottsdale, West Virginia University and UT San Antonio. And he’s now research professor at the University of Arizona Phoenix. Dr. Lamm has had a lifelong interest in urologic oncology and clinical trials and has a particular interest in immunotherapy and chemo prevention. He was awarded the initial NIH, the National Institutes of Health-funded contract to evaluate BCG immunotherapy of superficial bladder cancer in a randomized clinical trial. That was in 1978. The first control trial demonstrated the efficacy of intravascular BCG immunotherapy.

Subsequent NIH-funded research demonstrated the superiority of intravesical BCG over oral administration and efficacy of intravesical without percutaneous BCG immunotherapy. His subsequent SWOG studies demonstrated superiority of BCG immunotherapy over doxorubicin and mitomycin chemotherapy. That led to FDA approval of BCG for the treatment of CIS and approval of the Connaught strain of BCG for treatment of recurrent papillary urothelial cancer. A subsequent SWOG study, SWOG 8507, demonstrated that three-week maintenance BCG immunotherapy reduces tumor long-term recurrence by 27%, and significantly reduces disease worsening compared with standard induction therapy.

Dr. Lamm has authored numerous articles in such peer-reviewed journals as the Journal of Urology, the New England Journal of Medicine, Investigative Urology, Urologic Research, and Cancer. Dr. Lamm, thank you for joining our podcast.

Dr. Lamm:

It’s a real pleasure, Rick. Thank you so much for having me.

Rick Bangs:

Oh, our pleasure indeed. So you have had such a tremendous impact on the bladder cancer community and on the use of BCG as a treatment. How did you get started with BCG?

Dr. Lamm:

Well, it’s actually kind an interesting story. I was a second year, excuse me, a first year resident at UC San Diego going into the laboratory, and I was going to study bladder cancer because there was some evidence that reverse transcriptase inhibitors, that’s drugs that inhibit C type RNA viruses, would be effective. And the idea came to me when I was on the beach with my wife and with two professors, Dr. Geddes and Dave McCullough and everybody’s wives. And Dave rolled over to me and he said, “Don, you’re going into the lab, you’re going to study bladder cancer, why don’t you stick some BCG in those mouse bladders?” Well, we did, and that’s where it all started.

Rick Bangs:

Oh my gosh. Oh my gosh. And is this back in 1978?

Dr. Lamm:

This was 1973.

Rick Bangs:

Oh my gosh. Okay.

Dr. Lamm:

So it’s been a long time.

Rick Bangs:

All right, wow. Wow. Immunotherapy before it was cool of course. So what were the origins of SWOG-8507, sometimes referred to as the LAMM protocol, which focused on maintenance BCG therapy?

Dr. Lamm:

Yeah, Alvaro Morales was the first one to publish the six weekly installations, and that was in 1976, and it came in a six pack, but he also knew that it takes a while to develop the immune response and to stimulate it. And so he gave it weekly for six weeks, and actually there were 50 and 80 milligrams and he began, as I recall, with the 80 milligram dose. And that schedule was so good many people tried maintenance thinking that it would be better, but they failed. But I was committed to the idea that maintenance would be superior because the stimulation of BCG and other agents decreases with time. And the risk for bladder cancer recurrence continues, is really lifelong.

So I devised the three-week maintenance protocol. That was based on looking at the pathology of patients who had been given BCG and had bladder biopsies at three and six months. And the inflammation cystoscopically decreases at three months. The highest risk for a tumor recurrence is at three months. So we gave three, not six, because if you give too much, you can actually suppress the immune response. So we gave three at three months and at six months and then every six months up to three years. And that really quite dramatically improved the benefit of BCG.

Rick Bangs:

Okay. So I want to go back to this dosing issue. So how was dosing determined and even today is it optimized? I heard that doses were based on the standard amount of BCG in a vial that’s used for tuberculosis vaccination.

Dr. Lamm:

Yeah. Yes, that’s exactly right.

Rick Bangs:

Okay.

Dr. Lamm:

And the amount that comes in the vial is highly variable. There are milligrams which can be adequately, accurately measured, but what they use is a colony forming units, the bacteria that grow out from a sample of the vial, and it’s a lipid cell wall and it clumps. So it just depends on how many clumps you get that confuses. So you can’t get an actual count of the number of live bacteria. It ranges. It used to be two to eight, 10 to the eighth, excuse me, colony forming units and now it’s even less than that because, again, it’s so variable. But you may be getting three times as much or a third of what you hoped. The point is the range of dose is fortunately quite wide effect symptoms.

Rick Bangs:

So from patient to patient variability?

Dr. Lamm:

Yeah, we did a lot of animal model work and we found, and as others have seen, that if you give too much BCG, you can actually decrease the efficacy and it can actually get to the point where you can promote tumor growth in an animal model by overwhelming the immune response with a very, very high dose. But we haven’t seen that overdose when we give weekly for six weeks. It’s the single one-shot deal that seems to do it rather than repeated smaller doses. You can give a dose that would be immunosuppressive over several weeks, but if you give it all at one time, you get the immunosuppression. I don’t want anybody to worry about that because that’s just an observation in animals and nobody gets that much BCG.

Rick Bangs:

Right. You wouldn’t give me that as my doctor.

Dr. Lamm:

Yeah.

Rick Bangs:

Right. So in the US there are various strains, and the study that I referenced in your bio was about the Connaught strain. So can you tell us, you may want to explain what a strain is and then what’s currently available in the United States? How do they compare?

Dr. Lamm:

Yes. The only strain available for general use, there are strains that are being studied, but that’s under strict trial guidelines, but the only strain available commercially is the TICE strain of BCG. My work began with Armand Frappier’s strain from Canada, the same that Alvaro Morales used. And then the NIH decided, oh, well, we’re just going to give you Connaught strain. They’re both excellent strains. And now the Connaught hasn’t been available for a decade really, and it’s all TICE. TICE is very good as well. So fortunately, we have a TICE BCG manufactured by Merck, and there is a short supply, but it is available to many patients.

Rick Bangs:

Right. And there is a SWOG study that is going to report out, I believe, next year, because I’m the SWOG bladder cancer patient advocate so I believe it would be next year before it would report out on the Tokyo strain of BCG, right?

Dr. Lamm:

Yes. Robert Svatek where BCG originated for me clinically at UT Health Science Center, San Antonio, and he’s got a very, very interesting study comparing the Tokyo-172 strain and the TICE strain. You asked about strains, they’re really not strains, we call them that, but a very, very nice thing about BCG is that it was really life-saving when it came out. It increased its childhood survival fourfold in early childhood because it’s very good for TB in babies, but it stimulates Native immunity and protects them from all the other things that they can get as newborns. And doctors Calmette and Guerin, Calmette noticed that the child mortality was fourfold less in children who got BCG and then published that in 1930. And that’s been proven now around the world in poor countries. So this was such an important contribution that they didn’t patent it. They could have patented, it could have cost a lot of money.

Rick Bangs:

Oh my God.

Dr. Lamm:

But he just set it around to the company, governments primarily all around the world, and they would grow it and they would give it. And over the many, many passages, many decades before they changed the culture to having a stock culture that you went back to for your next culture and freezing it, it did vary quite a bit. So there are different sub-strains, if you might say, but I have not found one yet that doesn’t work for bladder cancer. There’s some variations, but they all seem to work. So if you can get your hands on one, I’d take it, whatever it was.

Rick Bangs:

Right, right, right. All right, so I think I heard you say that as a child, if you are immunized with BCG that get a tuberculosis vaccine, it also protects not just for the tuberculosis but for other things as well?

Dr. Lamm:

Yes.

Rick Bangs:

Wow.

Dr. Lamm:

Yeah.

Rick Bangs:

Wow.

Dr. Lamm:

And don’t get me started on that because it’s quite an amazing story and it would be a diversion, but there’s all sorts of… I’m sorry, I can’t not say it. The countries that vaccinate their children have a significant lower frequency of Type 1 diabetes, and also some studies have shown, Dr. Godfred has reviewed it, have shown a reduction in Alzheimer’s disease. There’s just all kinds of really good side effects of BCG. Including there was a big follow-up study published on Native Americans, and they vaccinated half of them as early childhood with BCG, and there was a statistically significant reduction in subsequent development of lung cancer and there matched for all the other things that cause lung cancer.

Rick Bangs:

Wow.

Dr. Lamm:

So it’s good stuff.

Rick Bangs:

Yes, yes. Okay. And we’re going to invite you back to talk about some of this other good stuff because you and I had that discussion earlier. So I think we definitely need to take you up on that. All right, so I’m a bladder cancer patient, I’m getting BCG. Tell me what does it mean if I have a reaction, I’m putting reaction in quotes, or if I don’t have a reaction. In other words, I’m having side effects or I’m not having side effects, what does it mean?

Dr. Lamm:

Most patients will have some increased frequency and urgency, sometimes a little malaise, even a low-grade fever. We don’t like to see high-grade fevers, but the low grade fevers, that is the typical BCG reaction. That has not been shown to be required. We do get worried a little bit about the patient who has no side effects because you weren’t worried if the bacteria died, but even dead bacteria work. And we’ve seen just a lot of patients who’ve never had a single side effect from BCG and have never had a single bladder tumor recurrence. So it does work in the absence of reactions.

Rick Bangs:

I see. Okay. So I shouldn’t worry if I don’t have a reaction. Okay. Yeah, because I think one of our guests did not have a reaction. Okay. So talk to me about the adequacy of current knowledge on BCG. It was like a very, very early, maybe it was the first immunotherapy, and so it’s a number of years later as you’ve pointed out. So what do we know and what are some future possibilities because maybe we don’t know some things?

Dr. Lamm:

Well, we continued to learn about the immunologic effects of BCG, and now it has progressed to not only the type of immune reaction, the T cells and the B cells and the antibodies and the cellular immunity and all sorts of cytokines that are produced, but it also changes the control of genes, the epigenetic effect. And they have recently done studies on this, and they found over 23,000 genes that were demethylated. Methylation is a way of silencing a gene and BCG, because of our 90 plus thousand year coexistence with the organism, we have developed a very, very complex reaction. And it’s not only the immune system, the Native and the adaptive immune system, but it’s the genes, the epigenetic control of genes that changes in response to BCG. That’s thought to be the mechanism for the benefit of BCG in autoimmune disease such as Type 1 diabetes.

Rick Bangs:

So how would you rate that knowledge versus some of the recent immunotherapeutics? So you started looking at this in the seventies, so it’s quite a number of years later, right? 50 years later. So if we think about 50 years of advancement and knowledge, do we know what you think we ought to know after 50 years about BCG and bladder cancer? I’m guessing you might have a point of view on this.

Dr. Lamm:

Well, the field has advanced just tremendously, and, of course, it’s not just BCG, but all of the new immunotherapies. The BCG, I don’t know if we’ll ever know entirely how it affects because it’s a complex living organism. The newer immunotherapies are specific molecules that you can figure out what is the characteristic response and so on and so forth. So in fact, I said 20 or 30 years ago when they were saying that BCG stimulates interleukin-II and interferon-gamma, that well, I’ll bet you it’s going to stimulate other cytokines, interleukin whatever, in the future, and I’ll bet it’s going to be a good thing for the stimulation of one of our unknown interleukin that happens. And that turned out to be true. They found many more, not only with BCG, but in the immune system. There’s so many, I can’t keep them straight.

Rick Bangs:

I go it. Gotcha. All right, so are there circumstances when a bladder cancer patient might need maintenance BCG, I’ll put this in quotes, “forever.” Are there circumstances that would be the case?

Dr. Lamm:

Well, I don’t think we know the answer to that question. The risk for bladder tumor recurrence, the main risk is that within the first three months, within the first six months, within the first year, and if you look at the recurrence curves, they tend to flatten out. But I’ve seen people come back decades later with a new tumor. For the low grade tumors, many now feel that it’s safe to infect it. It’s common to stop follow up cystose after a certain time. For the high grade tumors, I personally just did not feel comfortable. I think once a year is safe. Now there are markers that are being developed that are on the market that make it so it is very safe not to have cystoscopy. I know patients are very interested in avoiding the cystoscopy.

Rick Bangs:

Yes. For obvious reasons. If we can give some urine and you can tell us whether or not we need to get more BCG or do something else, I think I’d vote in favor of it.

Dr. Lamm:

There’s progress being made there. I’m not sure that we’re ready to give up, it’s not 100% the diagnostic accuracy by results.

Rick Bangs:

We can hope we get there because that would be a tremendous thing. Okay. So now, we talked about the fact there’s a shortage of BCG. I think it’s heated up again recently from what I hear. So the guidelines were adjusted as I understand it during the most current shortage when it started. So what does maintenance BCG therapy look like in the context of a BCG shortage?

Dr. Lamm:

Well, I have some thoughts that are not USDA approved.

Rick Bangs:

Not mainstream thoughts?

Dr. Lamm:

Not mainstream thoughts.

Rick Bangs:

Okay. All right.

Dr. Lamm:

Well, the guidelines are, and this I totally agree with, low-grade tumors don’t need BCG. There are other treatments. Chemotherapy and combination chemotherapy even. But the high-risk intermediate patient, the guidelines that it’s a patient who’s doesn’t have high-grade or T1, but has recurrent low-grade tumors despite the chemotherapy, the guidelines say that a year of full-strength BCG is sufficient. I think just we haven’t used our head, and I do a lot of, kind of garage science, garage laboratory stuff, you can increase the response to chemotherapy and I believe BCG immunotherapy as well, by simply warming the solution. No need to have it at room temperature, do it at body temperature and that speeds up the reaction. It only has so much time to absorb the BCG into the cell. And in chemotherapy it has been demonstrated that it’s clearly a concentration effect and not a volume effect, not a dose regardless.

The same amount of mitomycin in a small volume, 40 milligrams and 20 CCs is better than 40 milligrams in 60 or 80 CCs. It’s a concentration. You’re just getting into the cell, diffusing down a concentration gradient. Well, I very much think that the same thing applies to BCG. So if you’re going to use one-third BCG, you don’t use it in 50 CC volume, you use it in 16 CC volume. You could hold it longer, and it’s not been tested, but that’s the way I’ve done it for a couple decades. And you can give one-third BCG for three years and use less BCG than if you’re giving full strength for one year. That wasn’t what they tested. And so I think logic would say that, for me, that’s the way to do it.

And another thing that, yeah, in the European study, comparing three week maintenance BCG with three week maintenance epirubicin, they demonstrated a significant reduction in tumor recurrence with BCG, a significant reduction of metastasis of bladder cancer with BCG and a significant reduction in mortality. And the greatest benefit, surprisingly, was in patients who had intermediate risk BCG. They excluded carcinoma in situ because everybody agreed that CIS was best treated with BCG.

So I would’ve done it differently. And we haven’t proven, but I think that would be a better way to deal with the shortage. If you’re a sufficient year of one-third dose in a 16.6 CC volume, is likely to be better than what they found in the one-third dose in a 50 CC volume.

Rick Bangs:

So I think what I’m hearing you say is there’s still room for improved knowledge around dosing, right?

Dr. Lamm:

Yeah, there is. No question.

Rick Bangs:

I think the guidelines would reflect some of your thoughts if there were published studies that had been done, right?

Dr. Lamm:

Right. Right. I’m making this stuff up, what could you say?

Rick Bangs:

But it gets back to the central problem here is, there haven’t been sufficient studies around dosing and scheduling of BCG. Not that there haven’t been studies because obviously I’m talking to somebody who’s done some of them, but nonetheless, there’s still questions that could be answered.

Dr. Lamm:

And that’s true for just about every drug we look at. You take a protein pump inhibitor, it’s approved for two weeks and people take it for the rest of their life. And there’s a lot of things that are just not adequately studied because it costs so much to do a study.

Rick Bangs:

Right, right. Yeah, if this was a new drug and it was highly profitable, there would probably be some interest in doing some of these studies. But, okay. So now, you did mention the warming of BCG. Now, is that done in the US or is that done in Europe, or where would that be done?

Dr. Lamm:

I don’t know that it’s done anywhere other than some people may have had the same idea that I had. But it is done as proven with mitomycin and there’s a device and it’s to warm and so on, so forth. And it is clearly better than room temperature.

Rick Bangs:

Yeah, I knew I’d heard about warming. I wasn’t sure whether it was the BCG context.

Dr. Lamm:

It’s a general principle. There’s a lot of studies with intraperitoneal administration of chemotherapy that the warming, obviously it’s gentle warming.

Rick Bangs:

Right, right, right. Okay. Talk to me a little about how you think or expect, those could be two different things, that we’re going to get out of the shortage ditch that we have been in, well at least three times since I was diagnosed since 2006. So there’s at least three periods of shortage. I don’t know whether you call this recent activity an extension of the third or the fourth, but we’ve been struggling for a while.

Dr. Lamm:

It’s continuing. It is a fairly complex low tech manufacturing process, but it does involve a lot of ingredients, all of which, if there’s a change, have to be approved again by a regulatory agency. So the bureaucracy has to take some responsibility for this, I think. But I think the good news is that Merck is building the new manufacturing facility to come online ’25, I think. Then when they quit making Pasteur BCG, the French were a little bit upset that they invented BCG and they weren’t making any in their country. What’s with this? But the good news is that there is a manufacturing facility in Paris that is being developed and could also come online. Again, it’s like our inexpensive home building and so on, it’s the bureaucracy that’s slowing things up. That’s the problem.

Rick Bangs:

Now, the Paris-

Dr. Lamm:

In Paris, yes.

Rick Bangs:

The Paris plant is Connaught? Would that be the Connaught strain?

Dr. Lamm:

No, no. It’s not.

Rick Bangs:

Oh, it’d be something else?

Dr. Lamm:

Yeah. I think they are going to try to resurrect Pasteur BCG. There’s another one being developed in Amman, Jordan. Of course, there are a lot of potential problems there as well but bureaucracy is not one of them. They’re behind, I understand, on the actual building, but the paperwork is nearly complete. I’m kind of kidding about that. But they are working on that in Amman, Jordan.

Rick Bangs:

Okay. All right. And we know Merck is building a factory to manufacture the TICE strain. It’s not like you can just go anywhere. You have to have specialized equipment and all that. So why is it so difficult to make it and is it true, the rumor I heard, that BCG is grown on purple potatoes?

Dr. Lamm:

Yeah, purple potatoes. One of the shortage of purple potatoes that caused one of the problems. It can be grown in suspension in other ingredients, but yes, it is grown on purple potatoes. And once they approve a way of making it, you got to continue that way.

Rick Bangs:

Right, right, right. So it’s a biologic, right? We’re not making a molecular, we’re growing a biologic, if you will. So if I grow it, do I get 100% yield or there’s some variability? Could entire yields have to be destroyed? Is that some of the complexity?

Dr. Lamm:

Right. Yes, it takes many weeks to grow. And so if something happens, well, you got to have at least six weeks I think it is, if you’ve got to crank up increased supply and if something goes wrong with it, you’re out of it for another six weeks before you can get any out.

Rick Bangs:

Right. Because you lost all that time that you spent getting whatever it was growing that didn’t do what it was supposed to do. All right. So why wouldn’t suppliers be interested in and manufacturing BCG? Is there a profit, no profit in this? What’s the status?

Dr. Lamm:

There is some profit, but it’s given to over a million newborn a year and mostly in poor countries. So it can’t be too expensive or they’re going to be a large health cost to pay for not giving it. The World Health Organization at one of these shortages, they predicted that if there was a 6% shortage in the vaccination dose, there would be 7,600 unnecessary childhood deaths.

Rick Bangs:

Oh, wow.

Dr. Lamm:

So I don’t know why a government doesn’t get in this. It’s the right thing to do and companies do have to make a profit.

Rick Bangs:

Right, right. You don’t want the company’s not making a profit because they’re not going to want to make it and they’ll exit the business. So okay, I want to go back to the SWOG trial with the Tokyo strain. So that trial includes what’s called priming, and so patients are getting this small dose of BCG injected under the skin, I believe, on the upper arm, if I’m not mistaken. So what are your thoughts on using priming? Because the way, as I understand it that it works, they get the injection under the skin and then there’s a period of time where we wait and then they get the BCG, as opposed to going right into BCG instilled in the bladder. So what are your thoughts on priming?

Dr. Lamm:

Well, I think that’s got a very good scientific basis. It’s demonstrated in animal models to be superior. It makes good immunological sense. Your first reaction to an antigen takes a while. When you’re re-exposed, it’s a heightened and more vigorous response and happens more quickly. So there’s very good logic behind that, and I think it’s going to be an advance, and I think that’s a great study that SWOG’s doing. I would predict that Tokyo would be equal to TICE BCG. It’s just very frustrating that it takes so long-

Rick Bangs:

Oh, I know.

Dr. Lamm:

… to get these studies done.

Rick Bangs:

Right. Right. Okay. So we will have that discussion probably in a year or so when we get some results see what happens with the Tokyo strain, and what happens with the Tokyo strain where it also includes this priming in addition to in the bladder.

Dr. Lamm:

Yeah. So there could be two bits of good news for this.

Rick Bangs:

Could be. The more ways we can find to better use BCG, I think the better we can be, provided we can kind of work through the supply situation. All right. Are there other things that you can see that would improve BCG outcomes? We talked about priming. What other things are you aware of or can you think about that would improve?

Dr. Lamm:

Well, I mentioned the warming of the solution to body temperature or a little warmer. I think that would speed up the reactions. The concentration I think could be increased and the volume decreased. And I think the priming will turn out to be beneficial as well. We gave up the percutaneous vaccination again because six weeks of intravesical BCG was so good that it’s very hard to show that anything else is significantly better than that. There are potentially more applications. In terms of improving it, I don’t have any great ideas right now.

Rick Bangs:

Okay. No, that’s okay. That’s okay. We’ve already put several things on the table that either will or should get consideration. So in the foreseeable future, do you think BCG will be replaced or is it more likely that we’ll see treatments that are going to include BCG and a supplement or BCG and priming or BCG and something?

Dr. Lamm:

Yeah. I had the opportunity to participate in a study of patients who had recurrence despite BCG. And I’ll just tell you a story. This is a fellow who had severe chronic obstructive pulmonary disease and would’ve been a very, very high risk for not surviving a cystectomy. And he failed BCG induction, failed the subsequent three-week BCG. And at six months, I may have given him even another three weeks of BCG but I think at that point I was very concerned that he had carcinoma in situ and switched to gemcitabine and docetaxel. Again, both at normal or high concentration in a very small volume, warmed. We’ve just had excellent experience with that, and he failed that as well. And now we’re a year out and he’s still got disease. He would be the candidate for a cystectomy, but he couldn’t take it. And he was eligible for a study looking at BCG again, six weeks of BCG with a immune checkpoint blocker.

Rick Bangs:

Okay. Another immunotherapy.

Dr. Lamm:

Yeah, under avelumab. And he went and had a complete response. He went for two years with no recurrence, doing just fine. And that was just really amazing. So I think combination of BCG with the molecular immunotherapies may be very, very promising. And of course we now have the treatments that are virus gene therapies and it’s very, very exciting. But I don’t think they’re at all at a point where they can be considered a replacement to BCG. It’s very, very hard to get anything that’s better.

Rick Bangs:

Because it’s so…. Which not to say it’s 100% effective, but it’s a very effective treatment. Okay. So I’m looking for any final thoughts you have, any guidance on where you think we go from here?

Dr. Lamm:

Well, I’m just optimistic and look forward to seeing the shortage taken care of with new facilities coming online. And I’d like to see much more BCG used not only for bladder cancer, but other cancers. Who would’ve thought that a single shot vaccination of a baby would significantly lower his risk or her risk of getting lung cancer? And it’s quite consistent that even though you can give too much BCG in a one-time deal or not pay attention to the side effects and adjust the dose appropriately… I lost my train of thought. I was going to say that in the maintenance study, we also looked at six-week versus the three-week maintenance, and we looked at second primaries. A third of patients will have a cancer unrelated to the BCG either before, during, or after diagnosis. And the second primaries were significantly reduced. The one that was greatest and was statistically significant itself was prostate cancer. So there’s potentially a lot more uses for BCG, but we got to have enough of it to go around.

Rick Bangs:

Yeah, so a lot of exciting work’s been done, a lot of exciting possibilities, but supply is kind of a fundamental there, right. Okay. Dr. Lamm, I want to thank you for giving us a fascinating insider’s view of the evolution of BCG as a treatment for bladder cancer and what the future of BCG treatments might look like.

Dr. Lamm:

Thank you.

Rick Bangs:

If you’d like more information on bladder cancer, please visit the BCAN website. www.BCAN.org. Just a reminder, if you’d like more information about bladder cancer, you can contact the Bladder Cancer Advocacy Network at 1-888-901-2226. That’s all the time we have today. Be sure to like, comment and subscribe to this podcast so we have your feedback. Thank you for listening, and we’ll be back soon with another interesting episode of Bladder Cancer Matters. Thanks again, Dr. Lamm.

Dr. Lamm:

My pleasure. And thank you. And thank you to BCAN.