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BCG immunotherapy


Medical editor Bjørn Brennhovd MD
Urologist
Oslo University Hospital

General

Intravesical bladder immunotherapy with BCG (Bacillus Calmette-G uerin) is performed on all patients at a high risk for recurrence after a transurethral resection of the bladder (TUR-B). Upon instillation of BCG in the bladder, the bladder will start to produce antibodies, which will attack the cancer cells. 

  • Induction cycle: one instillation per week for 6 weeks
  • Maintenance/follow-up cycle: one instillation per week for 3 weeks  

Up to 50% of those who do not respond to the induction cycle will respond to a repeated induction cycle. Repetition of maintenance cycles for up to three years should be considered based on tumor risk and tolerability. In general, patients with high-risk tumors (Tis, T1G3) receive a full maintenance cycle. The procedure is performed on an outpatient basis. At the Norwegian Radium Hospital, when and how often the maintenance cycle is carried out is determined on an individual basis.

Indications

  • Three episodes of tumor recurrence within 18 months
  • Primary T1G2/3
  • Primary Tis, or possibly concomitant Tis in multiple localizations 
  • Multiple recurrences at the first or second follow-up after TUR-B, especially if there was primary multiplicity, or the primary tumor was large (³ 3 cm)

Goal

Treatment for superficial transitional epithelial cancer in the bladder (Ta, T1).

  • Reduce the chance of recurrence.
  • Prevent progrediation of the disease.

Equipment

  • Catheterization set with sterile gloves, swabs, compresses, forceps, drape, and pus basin 
  • Chlorhexidine® 0.5 mg/ml
  • Syringe 50 ml
  • Sodium chloride 9 mg/ml, 50 ml
  • Transition tube
  • Closed system for mixing and instillation in bladder 
  • Disposable catheter
  • Xylocaine® gel
  • Vial with Onco TICE® 12.5 mg (store in refrigerator, tolerates only a few hours at room temperature)
  • Gloves, coat, mask
  • Yellow bag for waste

  • Preparation

    • Prepare equipment for a sterile procedure.
    • Mix Onco TICE® 12.5 mg in 50 ml sodium chloride 9 mg/ml using a closed transfer system or under a LAF bench.
    • Ask the patient to urinate and provide a urine sample to test for possible UTI.
    • If there is a sign of infection, confer with a doctor before instillation.

    Information for the patient

    During treatment and two weeks following:

    • Sit to urinate to avoid spillage of urine.
    • Dry the opening of the urethra with paper and dispose in the toilet before washing hands with soap and water.
    • Use a designated towel during the entire period.
    • Be aware of people with a reduced immune response and avoid direct contact to avoid transfer of BCG. 
    • Men should use a condom during sex. 

    Provide general information about the treatment and possible side effects (see follow-up/observations).


    Implementation

    • Insert the catheter sterilely.
    • Empty the bladder.
    • Place the catheter tip of the transition tube into the catheter.  
    • Instill the BCG solution from the syringe. The fluid should infused gradually over 2 minutes.
    • Remove the catheter.
    • Put all used equipment into a yellow bag and into a biohazardous waste receptacle.

    Follow-up

    • The patient may return home after the treatment.
    • The solution should be kept in the bladder for 2 hours (if he/she is able to) 
    • Then the patient should urinate.

    Observations

    • Frequent and burning urination during the first days after each treatment is normal. 
    • Urine tinged with blood may be present.
    • Influenza-type symptoms usually the day of the treatment and the following day are normal. 

    Sometimes the patient may experience such intense side effects that treatment must be stopped.

    Follow-up

    • The first years after treatment, the patient will have follow-up with cystoscopy every 3 months. 
    • Further investigations are assessed individually.

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