BCG: maintenance treatment

About BCG

BCG (Bacillus Calmette Guerin) is a drug which we administer directly into the bladder. We use it to treat superficial bladder cancer or tumours. (Superficial means early-stage, or limited to the top layer of body tissue).

We usually give BCG to people with early bladder cancer who have a high risk of the cancer coming back and becoming invasive. (Invasive means growing into the surrounding, healthy tissue.)

This can include people who have:

• carcinoma in situ (CIS). This type of cancer cannot usually be removed completely with surgery. This is because it is flat and often widespread in the bladder lining.
• high-grade stage Ta and T1 cancers. (Ta means the cancer is in the inner lining of the bladder. T1 means means the cancer has started to grow into the ​​layer beneath the bladder lining).
• intermediate-grade T1 cancers, when there are several cancers in the bladder or one which is larger than 3cm/1in. (Intermediate means middle-level risk.)

BCG helps prevent the cancer from coming back in the bladder. It also reduces the chances of it becoming invasive. 

We will explain to you why we believe BCG is the most appropriate treatment for you.

How it works

BCG is a type of immunotherapy. Immunotherapy stimulates your body’s immune system to destroy cancer cells.

Doctors do not know exactly how BCG works, but evidence shows that it makes the bladder react in a way that triggers the body’s immune system to get rid of the cancer cells.

Typical treatment schedule

Your maintenance treatment consists of the following, which will start about a month after your flexible cystoscopy.

• To begin: 3 (weekly) BCG treatments, given in week 1, week 2 and week 3.
• 3 months later: a repeat course of 3 (weekly) BCG treatments.
• 3 months later: another repeat course of 3 (weekly) BCG treatments.

After that we may need to repeat this 3-week BCG course every 6 months. This maintenance treatment can continue for up to 3 years.

We will discuss the best schedule of treatment with you.

About each individual treatment

• Each treatment takes about 20 minutes.
• Treatment takes place at the Urodynamics Unit or Albany Unit. Your appointment letter will tell you which Unit to go to.

Preparing for treatment

Vaccines

Do not have flu or holiday vaccines for 14 days before or after your BCG treatments. (Vaccines can over-stimulate your immune system and stop the BCG treatment from being effective.)

Fluids

By drinking less you will produce less urine, and prevent the BCG drug from becoming too diluted. This will improve its effectiveness. Drinking less will also make it easier for you to hold onto the drug once it is in your bladder.

Water tablets (diuretics)

If you usually take water tablets in the morning, do not take them before your treatment (unless we tell you otherwise). You can take them when you are home after your BCG treatment.

High blood pressure tablets (antihypertensives)

If you usually take blood pressure tablets every day, do not take them on the day of your treatment. These tablets can cause a drop in blood pressure when combined with this treatment, and may cause you to fall or faint.

Eating

You can have solid food before your treatment, but no fluids. Do not drink milk, tea or coffee.

Driving

You can drive yourself home after each treatment.

On the day

When you arrive at the Unit, we will ask you a few questions. We will ask you to provide a urine sample. 

You can bring a sample with you from home. If you do this, follow these instructions.

• Collect the sample during the middle of your urine stream.
• Collect it in a sterile container.  We usually send you one with your appointment letter. You can also buy one from any chemist.
• Your sample must be no more than 2 hours old when you give it to us.

To carry out the treatment, we will do the following.

• Insert a catheter (small, flexible tube) into your bladder through your water pipe (urethra). Most patients do not find this painful, but it can be uncomfortable.
• Pass 50mls of BCG fluid into your bladder via the catheter.
• Remove the catheter.

If you are an outpatient, you can go home after the treatment. 

Next steps when you are home

After 2 hours, do the following while you are home.

• After 2 hours, you must pass urine (wee) into the toilet.
• We advise men to sit when they do this, to prevent splashes.
• Do not flush the toilet immediately after you pass urine.
• Add 2 cups of undiluted bleach into the toilet after you pass urine. Leave it for 15 minutes, then flush the toilet. (We recommend bleach because BCG is a live vaccine).
• Use soap and water to wash your genital area and hands after passing urine each time.

For 6 hours after you first pass urine (wee) at home, repeat these steps:

• Continue to pass urine whenever you need to.
• Men should sit when they do this, to prevent splashes.
• Do not flush the toilet immediately after you pass urine.
• Add 2 cups of undiluted bleach into the toilet after you pass urine, leave it for 15 minutes, then flush the toilet. 
• Use soap and water to wash your genital area and hands after passing urine.

Drinking fluids/pain relief

• As soon as you have passed urine, you can start to drink. Make sure you have plenty of fluids over the next 48 hours. This will flush the rest of the BCG out of your bladder.
• Do not drink alcohol on the day of your treatment.
• We advise you to take paracetamol 3 hours after your treatment. Do this even if you feel completely well. This will help to prevent you experiencing the fever or chills that can be caused by BCG.
• Always follow the instructions on the paracetamol packaging.

Side effects

Common

Common side effects usually disappear about 2 days after treatment. You can reduce some of these side effects by drinking plenty of fluids to flush the BCG out of your bladder. You can also take over-the-counter painkillers.

If you have an ongoing condition such as arthritis/rheumatoid arthritis, you may experience a flare-up.

Common side effects include:

• needing to pass urine often
• pain when you pass urine
• blood in the urine
• tiredness, general aching and a raised temperature (above 38C).

If these side effects do not clear after 2 days, make a GP appointment (see also 'When to seek emergency help' below.

Less common

• flu-like full-body muscle and joint aching, fever and chills
• nausea and vomiting
• coughing.

If these side effects do not clear after 2 days, make a GP appointment (see also 'When to seek emergency help' below).

Rare

• inflammation of the testicles
• bladder contractions
• inability to pass urine.

These rare side effects can be a sign of serious infection that needs urgent antibiotic treatment. 

If you experience any of these rare side effects, make a GP appointment or get in touch with us immediately (see Contacts below).

Follow-up

After each maintenance course of BCG, we will send you an appointment for a flexible cystoscopy.

A flexible cystoscopy is a bladder and urethra examination. It will enable us to assess how your bladder cancer has responded to your BCG treatment. We usually perform it as an outpatient procedure, in our Albany Unit.

We will schedule your flexible cystoscopy as follows:

• every 3 months during years 1 and 2
• every 6 months during years 3 and 4
• every 12 months from year 5 onwards.