BCG: induction (starter) treatment

About BCG

BCG (Bacillus Calmette Guerin) is a live, weakened bacteria which is used to vaccinate against TB (tuberculosis). It works by stimulating your body to fight the infection. It is also used to treat bladder cancer.

We use it to treat superficial bladder cancer or tumours. (Superficial means early-stage, or limited to the top layer of body tissue). To do this, we administer it directly into the bladder. 

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

Induction (starter) treatment

To start you on BCG, we will give you a course of 6 BCG treatments: once a week for 6 weeks. We call this the 'induction' (starter) course.

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.

If this treatment is not effective, we will discuss next steps with you.

If your BCG induction course is effective, we will continue with 'maintenance' treatment.

Future maintenance treatment

Maintenance treatment will follow this schedule:

• To begin: 3 BCG treatments, given once a week for 3 weeks (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 can continue for a further 2 years.

We will discuss with you how long your treatment will continue.

For more information on maintenance: BCG maintenance treatment [add link when ready].

Preparing for treatment

Vaccines

Do not have flu or holiday vaccines for 4 weeks before or after your course of 6 BCG treatments.

These vaccines may 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 morning 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.)

You can take your tablets later in the day, when you start to drink. (See 'Drinking fluids/pain/sexual activity', below).

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 them 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 at 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/sexual activity

• 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.

Tea, coffee, alcohol

• Tea and coffee can irritate the bladder. We strongly advise you not to drink caffeinated tea or coffee for the full duration of your BCG treatment (including on the day of treatment and the day after). You can drink decaffeinated tea and coffee.
• Do not drink alcohol on the day of your treatment.

Pain relief

• 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.

Sexual activity

• If you are sexually active, do not have sexual intercourse for 48 hours after each treatment.
• We advise you to use a condom for at least 10 days after each BCG treatment, and preferably for 6 weeks after each treatment.

Side effects

Common

Common side effects usually disappear about 3 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.

Common side effects include:

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

If these side effects do not clear after 3 days, make a GP appointment (see also 'When to seek emergency help' below).

Less common

• a continuing high temperature (above 38C)
• vomiting
• skin rash
• coughing
• a condition called 'reactive arthritis'. This can cause painful joints, red or sore eyes or urinary tract infection (UTI) symptoms. UTI symptoms include:
  • pain or a burning sensation when peeing
  • needing to pee more often or more urgently
  • pee that looks cloudy or contains blood
  • lower tummy pain or back pain (just under the ribs)
  • a high temperature or feeling hot/cold/shivery
  • a low temperature (below 36C).

If you experience any of these symptoms or feel generally well, speak to your GP immediately. You may need antibiotic treatment for serious infection. 

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 (see Contacts below).

Very rare

Make an urgent GP appointment or call 111, if you experience any of the following:

• shortness of breath
• difficulty breathing
• swelling of your face.

Follow-up

We will send you an appointment for a flexible cystoscopy, 4 to 6 weeks after you finish your induction (starter) course of BCG.

A cystoscopy is an inspection of your bladder and urethra, during which we will take a biopsy (a sample of tissue). This will enable us to assess how your bladder cancer has responded to your BCG treatment. Most people have this as an outpatient procedure in Kingston Hospital's Albany Unit.

You can expect a further telephone appointment, 2 weeks after your cystoscopy, to hear your biopsy results.