My father is 54, he was first found to have bladder cancer (superficial) in fall 2004. After the treatment of TUR, and followed by chemotherapy with Hydroxycamptothecin (from 2004 to 2006) and doxorubicin hydrochloride (from 2006 to 2008) placed in the bladder, the superficial cancer recurred twice in summer 2006 and May 2008 almost in the some position of the bladder. Is this kind of recurrences of bladder cancer normal for a bladder cancer patient? What could be the best way to do in the future to prevent the recurrence? Is BCG therapy the best choice?

Dear Friend,

We do not recommend BCG for low grade tumors, but when low grade, non-invasive tumors recur despite intravesical chemotherapy, as seen in your father, BCG is appropriate. Many urologists have avoided the use of BCG in patients with intermediate risk disease- Grade 2, recurrent or multiple tumors. However, data from the EORTC now confirm that 3 week maintenance BCG reduces recurrence, metastasis and cancer death in
patients with intermediate risk disease. We all now acknowledge that BCG is intravesical treatment of choice for high risk disease.

Thanks for asking,
Don Lamm,MD

Does age have any influence on efficacy or side efects in BCG treatment?

Dr. H

Dear Dr. H,

Yes, Dr. O’Donnell has reviewed his very large experience with BCG plus interferon and finds that those over 75 and, paradoxically, those under 50 have reduced response (higher tumor recurrence)than those under 75. Other studies have shown that older patients present with more aggressive disease and have a worse prognosis. I have not been impressed that older patients have any significant increase in side effects, but do not have
specific data on that subject.

Thanks for asking,
Don Lamm, MD

I want to thank you for your answer to my question concerning full or 1/3 strength BCG for maintenance. The answer could not have been more timely. I received your e-mail about an hour before getting my 3rd instillation of the 6 month maintenance series. I showed your e-mail to the urologist, but he said he felt my side effects were not bad enough to warrant reducing the dose yet. (The side effects I have had include bleeding for 4-5 hours, one fever of 100.6, and urgency and frequency lasting 18-24 hours.) He said he felt that full strength would be best for this treatment and if my July and Oct cystos are negative he would reduce the dose. Rather than argue the point, I agreed to full strength but only held it for 30 minutes. No fever and only 3 or 4 voids light to medium pink tinge. Urgency and frequency about the same. I take it that once you are sensitized during the induction phase, it takes less and less to trigger the immune reaction necessary for maintenance.

Again, thank you very much as I feel the side effects could have been much worse if I had held for 2 hours.

P

Dear P,

We don’t want to start a rebellion, but studies have shown that patients such like you who are actively involved in their care do better. I am glad the side effects of BCG are now tolerable. The Scandinavian study that advocated 30 minute retention as I recall did not find any reduction in efficacy.

With your permission, I think it would be helpfult to post your response
on the web as well.

Best regards,
Don Lamm, MD

Thanks so much for your question column. I’ve been diagnosed with CIS Bladder Cancer and have had one round of 6 treatments of BCG. The Cystoscopy 6 weeks after treatment showed there was still cancer there. It is 6 weeks later and I’m beginning my second 6 weeks round of BCG this week. My question is: Is it really necessary to use 2 cups of chlorine bleach in the toilet when voiding after the 2 hrs. of holding the BCG in the bladder
and again each time I void until 6 hours after treatment? We have a septic system which would not benefit from this much chlorine as it breaks down the bacteria needed for the septic to work. I also wonder if it is harmful to city sewers.

B

Dear B,

You can skip the septic tank chlorine. There are much worse (or beneficial?) bacteria in the toilet than BCG. We don’t have true direct comparison data, but I am very cautious about using a second 6 week course. With 3 instillations the CR at 6 months for those with residual disease at 3 months is 64%. Repeated 6 week courses did not improve maintenance of CR in a Spanish study of CIS, and does increase the risk of side effects. Side effects can be reduced by lowering the dose of BCG or holding for half an hour rather than 2 hours.

Thanks for asking,
Don Lamm, MD

My husband has been diagnosed with bladder cancer. It had penatrated the first layer of the bladder, but not into the muscle wall. The tumor was removed and second biopsy was done and removed some residual cancer cells. He did six weeks of the BCG. A biopsy was complete and found to be free of any cancer. During his six week treatment he did not have any side effects. He started a maintance (3wk), however, and the very first treatment he became ill that night with a fever which lasted through the night. The following day he was fine.

What would you recommend? I’m so fearful that if the treatment / maintance is not completed, the cancer will return. We were very lucky to catch it so early.

Dear Friend,

Your husband is right on track and appears to be in very capable hands. You are correct in being concerned about his fever with the first of the 3 BCG maintenance instillations. Be reassured, however, that there are several ways to avoid future problems for him.

Specifically, they are as follows:

1. He can have the dose of BCG reduced to 1/3 or less.
2. He can hold the BCG for only 30 minutes after instillation, or
3. He can take an antibiotic such as Ofloxacin 6 hours after BCG instillation.

Each of these techniques have reduced BCG side effects, and if needed they can be combined. On the bright side, patients who have fever after BCG have been reported to have a significantly reduced risk of tumor recurrence.

Thanks for asking,
Don Lamm, MD

Male 65 yrs old, Bladder cancer

Nov 09, 07. Biopsy result:

C biopsy:posterier wall:Flat urothelial carcinoma in sutu [Monomorphic variant]
D Biopsy Rt. bladderwall:Flat urothellial dysplasia.
E Biopsey Left lateral bladder wall: no diagnostic abnormality

Comments:
There might be a spectrum of opininon speciman C. as it is as it is at the lower end of CIS spectrum [ ie versus urethelial dysplasia]. Neither Cor D shows the striking degree of atypia/pleomorphism seen incytology specimen 07s005193 raising the possobility of a missed liason.

Jan 12, 08
Six weekly BCG given .

March 28, 08
Cytoligy report after BCG. Speciman voided urine.
Clinical data:Hx of bladder Ca
Investigation required: Tumer Cells

DIAGNOSIS:
Highly atypical cells suspicious for transitional cell carcinoma are present.

Cystoscopy scheduled June 18 ,08

My question is:With the above finding should a another BCG be scheduled about June 18, 08 or? Your opinion would greatly be appreciated. If a charge would incur to get a answer I am okay with that. Dr. Lamm I applaud your move to Arizona where you have more freedom to invoke your knowedge and research findings.

Forever Thankful,

H

Dear H:

Yes, while CIS is considered an aggressive and dangerous malignancy, there are clearly different categories of CIS. Focal, asymptomatic disease, which you appear to have, is much less aggressive than diffuse, multifocal disease that causes frequency and dysuria (burning with urination). Despite your lower risk, in my opinion you should definitely be treated with 3 week maintenance BCG. This schedule has recently been reported by the EORTC to significantly reduce the risk of metastasis and cancer death. To the best of our current knowledge, maintenance BCG is required to reduce the risk of bladder cancer progression and the 3 week schedule I devised for the Southwest Oncology Group appears to be the current best regimen.

Thanks for asking,
Don Lamm, MD

I am a 51 year old female diagnosed with non-invasive bladder cancer high grade in 2006. I am being treated at the IU Med Center in Indianapolis. I have had the 6 treatments of BCG and 3 series of maintanence every 6 months thereafter. My last treatment was Feb 7, 2008, and it was very painful. The good news is that there are no signs of cancer. I still have pain when I walk, urinate and especially when I first stand up. I have to urinate about every 20 minutes. My last scope was a few days ago and my doctor could see the redness (like sores) inside my bladder from the BCG. I am still in a lot of pain and want to know how long this will take to heal. I am taking oncovite, and trying to watch not to eat alot of acidic foods. This has really hurt my quality of life. Do you have any suggestions? Will I ever heal up?

Dear Friend,

You have severe symptoms of BCG cystitis, and unfortunately without treatment (and even with it) symptoms can persist for months and months. Personally, I would recommend that you begin treatment with both a fluoroquinolone such as Ofloxacin and isoniazid. You must be very patient. Even with appropriate treatment it can take weeks, even months, for symptoms to resolve. I guess the good news is that you will not need BCG for a long time, and when you do need it you could get by with as little as 1/100th dose.

Thanks for asking,
Don Lamm, MD

My husband, who has Crohn’s Disease, has been undergoing BCG treatment for bladder cancer. His first 6 treatments went well, but he has been experiencing significant side effects with the past 2 treatments (8 and 9), including extreme pain during urination, urgency even when very little urine is actually passed, pain when walking. He was having considerable pain even before the last treatment, so the possibility exists that he received a treatment with an active UTI. Subsequent to the treatment, the pain worsened and he also developed a very large swelling in a gland in his neck.
The gland swelling has responded to Cipro, but the pain is ongoing.

Questions:

1. Is it safe for him to be receiving BCG treatment with a history of Crohn’s Disease: does this increase his vulnerability to a systemic BCG infection?

2. Is he likely to have suffered permanent damage if he received a treatment with an active UTI?

3. What course of action would you recommend, given that he is still experiencing very considerable pain?

Dear Friend,

I am sorry to hear your husband is having trouble with his BCG treatments. I know of no containdication or increased risk of BCG in patients with Crohn’s disease. These symptoms are not uncommon if BCG is given in the presence of an ongoing infection, but can occur even without that. When such symptoms occur we reduce the dose of BCG, and if they persist we proceed with specific antibiotics, usually Cipro and Isoniazid. There should be no permanent damage and he should respond to this treatment.

Thanks for asking,
Don Lamm, MD

At the age of 12 in the UK, both my sister and I showed a reaction to the initial BCG test,and did not require the vaccination against TB.I asssume this indicates that we had been exposed to TB as children,and had developed an immunity as a result.Could this exposure have resulted in an inflammatory reaction which could explain why both of us have Interstitial Cystitis of the bladder,(with ulceration),discovered on our 40’s.I only put this question because I see that BCG installations are now used to treat IC.Perhaps it is only a coincidence.As for bladder cancer,I am told that I have no greater risk than the next person.This is not tested for however.

Dear Friend,

I am sorry to hear that you and your sister have interstitial cystitis. As you know it can be a very debilitating and frustrating disease. To my knowledge there is no association between IC and exposure to TB. TB can cause bladder contraction, and this can occur with BCG as well, but fortunately it is rare. BCG has been used with some success to treat interstitial cystitis. Because BCG can cause side effects similar to IC, most use it as a last resort.

Thanks for asking,
Don Lamm, MD

My total knee is 7 months post op. What should I do as regards BCG and the possibility of infection of the knee.I have had Ta tcc spread in time and space in my bladder in the last 6 months [5 tumors low grade].

Dear Friend,

BCG has infected arterial grafts, but I have not seen any reports of infected joints. There is, of course, the theoretical risk, and BCG can cause arthritis. Dr. Wittes, formerly of Connaught laboratories, reviewed our SWOG BCG maintenance data specifically looking for any infections of artificial joints. The study was never published, but as you would expect many of the patients had joint replacement, and none became infected. I believe the standard interval is 6 months, but I would check with your orthopedic surgeon for his recommendation.

Thanks for asking,
Don Lamm, MD