Immunotherapy

BCG INTO THE BLADDER


If you have decided to have intravesical therapy with BCG, you will usually have BCG treatment weekly for 6 weeks. You may then have further BCG therapy 6 weeks after that, and then periodically for the next 3 years - maintenance BCG therapy.


The following is an extract from the BRAVO Overview Report written by Professor James Catto (Professor in Urological Surgery, University of Sheffield).  BRAVO is a clinical trial comparing radical cystectomy against intravesical immunotherapy:  'BCG therapy avoids radical surgery and is reported to provide a reduction in progression by 5% at 2.5 years.  However, BCG therapy can be poorly tolerated, its impact upon progression is debated and there are currently still manufacturing problems. BCG therapy potentially involves 27 intravesical instillations and 10 cystoscopies over 3 years.  Many patients (74%) report local and systemic toxicity, so only 30% of patients complete the full 3 years of treatment.  The main benefit of BCG therapy is bladder preservation and presumed better quality of life than with radical surgery.  However, there is little research to support this presumption as repeated cystoscopies, recurrence and the administration of the BCG can impair bladder function.' 


See the NHS England Patient Decision Aid for High Risk Non-Muscle Invasive Bladder Cancer that compares BCG therapy and Cystectomy for more detail - http://sdm.rightcare.nhs.uk/pda/bladder-cancer

 

HOW BCG IS ADMINISTERED

You will be asked to pass urine to make sure the bladder is empty.

You will then have a tube (catheter) put in the urethra.  The BCG is a liquid and will pass through this tube directly into the bladder.

 The catheter is then usually removed.  Sometimes it may be left in and clamped.  You shouldn't pass urine for 2 hours. You can walk about whilst the BCG is in your bladder.  When you do pass urine, you will need to be careful for 6 hours after the treatment as the vaccine contains live TB.

The treatment session will take a little over 2 hours after which you will be able to go home. You should feel well enough to drive yourself home after the treatment.

After your first few treatments, if you live within easy reach of the hospital and have your own transport, you may be allowed to go home with the medication in your bladder and pass urine at home after two hours.

If you are elderly or have mobility issues, you may wish to arrange for a friend or relative to accompany/collect you.   You will be able to carry out your normal activities after treatment. There are no restrictions on driving, work etc.

AFTER YOUR BCG TREATMENT

When the BCG has been in the bladder for 2 hours you will be asked to pass urine into the toilet (men should sit rather than stand to prevent splashing) and you should try not to get urine on your hands and should wash your hands well afterwards as the BCG may also irritate your skin.

If the catheter was left in the bladder during your treatment, the BCG will be drained back into a bag before the catheter is removed.

If you would like something to drink you can now do so.

Sex - you should abstain from intercourse/oral sex for 2-3 days after each treatment. The use of condoms thereafter is advised and should continue to be used for several weeks after your treatment has been completed.

Pregnancy - the effects on pregnancy are unknown. If you are planning to have children you should discuss this with your doctor as female patients of child bearing age are advised to use birth control during treatments and to wait at least 2 years before conceiving, longer if on maintenance treatment.

Breast feeding is not advised when having BCG treatment

SPECIAL PRECAUTIONS AT HOME

All the urine you pass during the first 6 hours after treatment should be treated as contaminated. After you have passed urine, it is recommended that you pour 2 cups of household bleach into the toilet and leave this for 15 minutes before flushing.  Ensure no one uses the toilet during the 15 minutes or before flushing.  Bleach neutralises the live BCG TB vaccine and you should continue to do this for 6 hours after treatment.

Wash hands/genital area with soap and water each time after passing urine for 6 hours after your treatment.

ARE THERE ANY POSSIBLE EFFECTS FROM THE TREATMENT?

9 out of 10 people having BCG will develop some side effects; these usually begin within 3-4 hours after treatment and may last 1-3 days.

Common treatment effects

You should tell your doctor at your next appointment if you have any of these symptoms.

  • Some bladder discomfort - an irritation rather like a urine infection.
  • Flu-like symptoms which can last for 1-3 days after each treatment.
  • Wanting to pass urine more often than usual or more urgently, which can last for two to three days.
  • Failure to complete the course of treatment due to discomfort in the bladder.
  • Blood or debris in the urine.
  • Painful joints.

Drinking 2 litres of fluid daily, unless advised otherwise, and avoiding tea/coffee for 24 hours after treatment will help flush any remaining drug out of the bladder and may ease the above symptoms.

Occasional

  • Narrowing (stricture) of the urethra following repeated use of a catheter.
  • Inflammation which can affect various parts of the body (the liver, joints and the back of the eye).

Rare

  • Persistent or severe pain after treatment, sometimes leading to removal of the bladder.
  • Generalised and possibly serious infection with the BCG bacteria needing treatment in hospital with powerful antibiotics. This is not TB and there is no risk of catching TB from the treatment.

Very rarely - less than 1 person in every 100 - may experience more serious treatment effects.

Contact your GP/Nurse immediately if you have any of the following:

  • Urine is cloudy/offensive smelling
  • High Temperature over 38°C for 48 hours
  • Joint pain
  • Skin rash
  • Cough
  • Fever and chills
  • Feeling sick or vomiting
  • Feeling extremely tired

See a doctor or attend A&E immediately if you develop:-

Shortness of breath

Difficulty breathing

Facial swelling

You need to inform them that you have had BCG treatment

FOLLOW UP

After you have completed your treatment you will be booked to have a cystoscopy in approximately 6 weeks time. This is normally carried out using general anaesthetic or spinal anaesthetic unless your doctor tells you otherwise. Biopsies may be taken at this time. You will be able to go home the day of or the day after your operation.

FURTHER TREATMENT

Your doctor may decide to continue with maintenance therapy to reduce the risk of bladder cancer recurring. This involves having BCG once a week for 3 weeks at 3, 6, 12, 18, 24, 30 and 36 months following your first treatment.

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