What to Know About Bacillus Calmette-Guerin (BCG) for Bladder Cancer

Bacillus Calmette-Guerin (BCG) is an immunotherapy derived from bacteria used to treat some kinds of bladder cancer. The body’s natural response to BCG is thought to help the immune system better respond to cancer cells. It is given as an intravesical therapy, inserted through a catheter to reach the interior of the bladder. TICE BCG is the brand name of the BCG intravesical therapy that is currently on the market.

History of BCG

Around the turn of the 20th century, researchers were working hard to develop a vaccine to prevent tuberculosis. Two researchers, Calmette and Guerin, began investigating the bacteria Mycobacterium bovis in their lab. This bacteria is closely related to Mycobacterium tuberculosis, the bacteria that causes tuberculosis infection.

Eventually, Calmette and Guerin developed a weakened strain of Mycobacterium bovis which they used to develop a successful vaccine against tuberculosis. This became known as the BCG vaccine, for “Bacillus Galmette-Guerin,” the strain of bacteria the pair had produced.

Several types of injectable BCG vaccine are still used in many parts of the world where tuberculosis infection is common. It is still the only type of vaccine used to help prevent tuberculosis.

In the mid-1970s, researchers found a new way they could use BCG bacteria in medical treatment. They found that if they injected live BCG in a liquid solution into the bladder, it helped prevent bladder cancer from coming back. The live bacteria in the bladder altered the person’s immune response and improved their ability to fight off the cancer. This is the type of BCG immunotherapy that is still used for some people with bladder cancer today.

Uses

BCG is recommended following tumor removal for some people with non-muscle invasive bladder cancer (NMIBC). In this kind of bladder cancer, the muscular bladder wall has not yet been affected. BCG is recommended for people with high-grade tumors (which look more abnormal under a microscope). It is recommended for some lower-grade types of NMIBC tumor as well. It is still the first-line treatment for these types of cancers. BCG therapy has not been approved for treatment in children.

One of the big problems of treatment of NMIBC is that often the cancer will come back after treatment. It’s thought that BCG treatment may reduce the chances of the cancer returning (called “recurrence”). Because of the risks associated with BCG, is it not recommended for people with subtypes of non-muscle invasive bladder cancer with the lowest risk of recurrence. It is also not a helpful treatment when cancer has spread into the muscular wall of the bladder or when it has spread to other places in the body.

BCG vaccines can be used to prevent tuberculosis, and they are still used in much of the world. However, that requires using and packaging BCG in a different way. TICE BCG is placed in the bladder via a catheter when it is used as immunotherapy for bladder cancer. When used in this way, BCG will not prevent tuberculosis. TICE BCG is also not a vaccine that can be used to prevent cancer.

Currently, BCG is only medically approved for the treatment of bladder cancer, not for other cancer types. Some research suggests that BCG therapies might also help fight other cancer types, such as stomach cancer, but currently, it is not approved for other cancer treatments.

Before Getting BCG

Before you start BCG, you’ll need to talk with your healthcare provider to make sure BCG is the best treatment for your NMIBC. You might have other options, like not doing BCG or picking a type of chemotherapy to be inserted into the bladder instead.

BCG therapy usually follows a procedure called transurethral resection of bladder tumor (TURBT). This treatment removes all visible cancer in the bladder. It also provides information about whether BCG or another treatment option might be a better idea. BCG is given two weeks or more after the TURBT procedure.

You may also need to be evaluated for tuberculosis, since BCG is not suitable for people with active tuberculosis infection. Depending on the situation, this might require assessments like a PPD skin test or an X-ray.

You’ll need to tell your healthcare provider about your medical history, including any prescription or over-the-counter medications you are taking. That will help your clinician make sure BCG therapy is safe for you.

Precautions and Contraindications

BCG should not be used in people who are immunocompromised, such as from medical conditions like AIDS or from genetic medical conditions. People taking medications that can suppress their immune system (like corticosteroids or cancer therapies) should also not take BCG.

People who are pregnant should not take BCG therapy if possible. Pregnancy should be avoided while a person is undergoing BCG therapy, and breastfeeding is also not advised.

People who have certain types of medical issues should wait until these resolve before having BCG. For example, you should wait if you currently have a fever, urinary tract infection, blood in your urine, or if you recently were injured during urinary catheterization. You should also finish any antibiotics taken for another medical reason before you have BCG therapy.

How BCG Therapy Is Done

BCG as an immunotherapy for cancer is given through a catheter into the bladder, never intravenously or as an injection. This is usually done in an outpatient setting. The professionals there will assemble the BCG so that it can be safely administered.

Your clinician will give you specific instructions about how you need to prepare ahead of time. You may need to limit your fluid intake before the procedure. Just before it, you’ll need to empty out your bladder.

The urinary catheter is inserted through the urethra (the tube carrying urine to the outside of the body). The solution containing the BCG is injected into the catheter. The catheter is clamped to help the BCG remain inside the bladder, where it can start to work. You may be asked to roll around a bit to help the medication reach all parts of the bladder. After a couple of hours or so, the catheter is unclamped. The fluid drains away, and someone removes the catheter.

Because BCG therapy includes an active, live bacteria, you’ll need to take certain precautions. For about six hours after the treatment, you should urinate while seated (to avoid urine splashing). During this time, you should also add bleach to the toilet for 15 minutes before flushing. This will help disinfect the toilet. You should also wash your genital region and your hands carefully. After the treatment, you should increase your fluids to better help flush out the bladder.

Men receiving treatment should also avoid having sex for 48 hours, since BCG might be passed to their partner. If you do have sex during your course of treatment, you’ll need to use a condom.

People receiving BCG usually undergo multiple rounds of therapy. You might have it once a week for six weeks. After that, you might have some repeated follow-up treatments for a period of months or a few years. Your healthcare provider will work with you to determine your exact schedule.

Side Effects

It’s not uncommon for people to experience temporary symptoms after BCG therapy. Some of these might include

• Burning with urination
• Increased urinary frequency
• Small amounts of blood in the urine
• Fever and chills
• Fatigue

Such symptoms usually only last a day or two.

Severe complications from BCG are uncommon, but they do sometimes occur. Because BCG does involve active bacteria, it can sometimes cause problems if the bacteria spread in the body.

Although it is uncommon, such infections have occasionally occurred in multiple body systems, including the lungs, liver, kidney, prostate, bone, and parts of the urinary system. Specific symptoms vary based on the organ involved. It is extremely rare, but infections related to BCG have sometimes led to sepsis (an overwhelming response to infection) and ultimately to death.

Treating Complications of BCG Therapy

If you do experience a problem from BCG infection, you may need to receive targeted antibiotics, such as isoniazid and rifampin.

Complications of BCG therapy sometimes don’t occur until years later. That can happen if the BCG bacteria that spread in the body become reactivated. These complications can sometimes be tricky to diagnose. Medical imaging might first make your clinician concerned about cancer or about another type of bacterial infection.

Make sure that all your medical care providers know that you have had BCG therapy. That will help guide their diagnostic process and ensure you get the best possible care. In some cases, your clinician will want a tissue sample from the involved area to make sure that the problem is from a BCG infection and not from some other source.