I must tell you that you and your expertise has helped me so much… thank you.

Question: I am 53yo male, Caucasian dx with bladder cancer TCC Ta Jan 2010,  status post TURBT 4 tumors removed largest 3cm and 6 BCG tx. 2nd scope today, no tumors however multiple spots on top of bladder - Urologist advises possible reaction to BCG - last tx 3 weeks ago or CIS? could TCC Ta have converted in less than 4 months? opinion? scheduled for biopsy - waiting is sometimes the hardest part. Thank you for your precious time!!

A. M.

Dear Allen,

Yes, it is very common, indeed expected that there will be reaction in the bladder from BCG.  This is, generally speaking, a good thing.  Cytology will likely be negative, in which case it is not required to do a biopsy.  Be sure, if you can, to get 3 week maintenance BCG.  Recent data now show it reduces death from bladder cancer by more than 60%- that less than half as many deaths as with other treatments. Best regards,
Don Lamm, MD

Thank you very much!

Dear Friend,

I am sorry to hear of your father’s bladder cancer and symptoms of Alzheimer’s disease.  BCG has been used to test immune function in patients with Alzheimer’s, and evidence shows that Alzheimer’s is associated with an impaired immune response when compared with patients of similar age.  I have found no reports of Alzheimer’s being promoted by BCG.  The diagnosis and treatment of cancer is a major stress, and it could be that this has aggravated symptoms of memory loss.  Hopefully this will be temporary, but he should see a physician for this.

Thanks for asking,
Don Lamm, MD

Dear Friend,

Unfortunately there is a recent publication by a renowned, but in my opinion not well informed urologist that questions the value of maintenance BCG.  This, in my opinion, is potentially a deadly error.  My SWOG study showed that compared with  6 week induction BCG, 3 week maintenance significnantly reduced recurrence and disease progression.  Survival was also increased but this advantage did not reach the level of statistical significance (overal survival increasing at ten year “only” from 52 to 58%).  It is true that several maintenance studies using regimens other than 3 week maintenance have been unsuccessful, but when studies are combined in meta-analysis maintenance is clearly superior.  My work has been recently confirmed by the EORTC.  In a study of 957 patients followed for 9.2 years 3 week maintenance BCG significantly reduced recurrence, metastasis, and overall as well as cancer specific death.  I a study in press from Dr. Akaza in Japan, 3 week maintenance was again confirmed to reduce recurrence and progression.  That study treated for only 18 rather than 36 months, and recurrence began to increase one year after completion of treatment.
So, if your doctor wishes to reduce your risk of recurrence, progression, metastasis and death he would be well advised to use the 3 week maintenance schedule.

Thanks for asking,
Don Lamm, MD

Thank you.

Dear Friend

I hope your mood has improved.  Maybe you were overdue for a good cry?  Having a diagnosis of cancer is like getting hit by a truck.  I have not seen any reports of BCG causing depression, but having bladder cancer certainly can cause depression.  With appropriate treatment, and the best we have is still BCG, you should do very well.  You may need to have the dose of BCG reduced to avoid increasing side effects.
I hope you will soon be back to your happy state.

Best wishes,
Don Lamm, MD

Best regards,
Mr. I. L.

Dear Friend:

Response to BCG immunotherapy is limited by the volume of tumor.  In the mouse, only 1×10*3 cells can be reliably killed by BCG immunotherapy.  In men, the number is much higher.  Complete response rates for papillary tumors are about 60%.  Resection is important not only to reduce the tumor burden and improve response, but to establish the diagnosis, grade and stage of disease.

Thanks for asking,
Don Lamm, MD

Dear Friend,

To my knowledge there is no problem with having a pacemaker or taking Micardis while on BCG.  You need to stay on warfarin as recommended by your cardiologist, but there are some reports that warfarin and other blood thinners can reduce the efficacy of BCG.  Other reports have not found this to be a problem.  With the 3-week BCG maintenance schedule you should  do fine while on warfarin- it is sufficient to cover any small differences in response due to other influences.

Thanks for asking,
Don Lamm, MD

Thank you
R. B.

Dear Regina,

I am sorry to hear about your disease.  Everyone cannot be treated with surgery, even though we think it has the best chance of cure.  Even with surgery we generally recommend chemotherapy before the procedure because it increases survival at 5 years by nearly 15%.  For those who are not medically fit for surgery (it is a very big procedure, and complications are common) chemotherapy plus radiation can be used, and it too can be curative.  There are chemotherapies that are well tolerated, but as you probably have heard the “big gun” chemotherapies can be very tough to go through.  Radiation alone, we believe, is inferior, but it too, when combined with a thorough, complete TUR can be curative.  If you decline or cannot take any of these treatments, complete TUR plus BCG can be used.  With no treatment local recurrence, with bleeding, and eventual spread would be expected.  The course is highly variable, from a few months to a few years.

Best regards,
Don Lamm, MD

I am a 65 year old woman who was diagnosed with bladder cancer last March. I am happy to report that all tests done in January showed no new cancer cells!  I am currently having my second set of maintenance treatments.  I am not sure if I am receiving the full strength now.  I have been thinking that I should ask for a reduced strength from now on.  I cannot tolerate more than 10 minutes on each side now.  Is 40 minutes effective?   At what point does quality of life become a factor in continuing treatments or not?  My doctor said he likes to get in at least 12 treatments, but he said any time I want to call it quits I could.

Also, as you can well imagine, I am urinating frequently, up every two hours  at night when I’m in between the maintenance series. Last night I was up every hour (my last treatment was Thursday).  Because my bladder has shrunk so much,  I  really have to plan my trips carefully and limit fluids before I leave home. How do you respond to these concerns?

Thank you very much for the opportunity to ask you these questions.

Dear Friend,

It is good to hear that you are cancer free, and in my opinion YES, YOU NEED TO CUT BACK ON BCG!  There seems to be no end to the misconception that more is better with BCG.  There is no need to suffer.  From your symptoms, it sounds like you need to hold off on BCG and when you start back, reduce the dose to 1/10th or less.  We are indebted to the Scandinavians who demonstrated that by holding BCG for only half an hour, the benefit of reduced dose can be obtained without having to do the math of dilution.

Thanks for asking,
Don Lamm, MD

Do you have any suggestions?

Dear Friend,

CIS that persists after BCG therapy is dangerous, and at risk of progressing to muscle invasion.  Cystectomy in some patients can be life saving.  It is not, however, the only choice nor necessarily the best choice for all patients.  Your urologist is right to check the upper tracts and prostate, where CIS can hide and be very dangerous. BCG induction with 6 instillations is suboptimal, but failing to respond to BCG plus interferon is worrisome.  The recommendation for cystectomy is therefore appropriate.  Alternatives would include intravesical chemotherapy.  Mitomycin C and doxorubicin have response rates in the range of 50%, when given initially.  After BCG failure the response would be less.  There is an approved agent for BCG failures when cystectomy is not appropriate: Valstar.  Combination therapy with MMC followed by doxorubicin as well as new agents such as gemcitabine and docetaxel can also be used. After responding to chemotherapy, I would recommend getting back on 3-week maintenance BCG.

Thanks for asking,
Don Lamm, MD

Thanks for your time.

Sincerely,
D. R., Baton Rouge, LA

Dear Friend,

There is no need to suffer with 3 week maintenance BCG.  The dose can be reduced to 1/100th, and Ofloxacin or Cipro can be taken 6 and 20 hours after instillation to reduce side effects.  Also, when side effects are strong, the interval between treatments can be increased.  You should do fine with 3 weekly instillations every 2 years now.

Good luck, and thanks for asking,
Don Lamm, MD