Bladder Cancer and BCG Immunotherapy: Benefits, Risks, and Treatment

What Is BCG Immunotherapy?

BCG, or Bacillus Calmette-Guérin immunotherapy, is a treatment in which the doctor delivers the immunotherapy drugs directly to the patient’s urinary bladder through a catheter.

It is intravesical immunotherapy because the drugs are directly injected into the urinary bladder.

BCG immunotherapy differs from other oral and injectable medications because it specifically targets the cancer cells in the bladder lining and has no adverse reactions on the other body cells.

The drug is a liquid derived from the strain of Mycobacterium bovis, the bacteria used to develop the tuberculosis vaccine (the BCG vaccine). When this bacterium is used in the drug, it is weakened so as not to harm the body.

BCG treatment is usually done after the transurethral resection of a bladder tumor (a surgery done to remove cancer).

What Conditions Can Be Managed With BCG Treatment?

BCG immunotherapy is mainly used to treat early-stage bladder cancer. Early-stage bladder cancer occurs when the cells remain confined to the bladder and do not invade the bladder wall muscle.

Bladder Cancer:

• Early-stage bladder cancer is non-invasive muscle bladder cancer and carcinoma in situ (CIS is a condition in which the abnormal cells look like cancer cells and have not spread to surrounding tissues). The limitation of BCG treatment is that it is ineffective against bladder cancer that has metastasized or spread to other body parts.

• In high-risk cases, such as CIS, BCG immunotherapy is used to reduce recurrence and progression after tumor surgery.

• BCG is given after transurethral resection of bladder tumor (TURBT) to kill residual cancer cells and stimulate an immune attack at the site.

Fibromyalgia and Diabetes:

Some clinical trials are being done to test the BCG therapy’s effectiveness for fibromyalgia and diabetes. Some experts believe that BCG treatment could help eliminate these diseases because it stimulates the production of cytokines.

Others:

• BCG treatment for bladder cancer should not be confused with intravesical chemotherapy and immunotherapy because different drugs are administered in both treatments.

• Cancer drugs, or chemotherapeutic agents, directly attack cancer cells, whereas immunotherapy drugs enhance the immune system's power and capabilities.

How Does BCG Immunotherapy Work for Bladder Cancer?

BCG immunotherapy for bladder cancer is often suggested after your bladder cancer is taken out surgically. You might be thinking, What is the need for BCG immunotherapy if the bladder cancer has already been removed. Let’s clear it off. Even if the cancerous cells are surgically removed from your bladder, there might still be some cancer cells that are left out or missed, or somehow escaped the surgical removal.

Let’s discuss how BCG immunotherapy works for bladder cancer in detail:

• BCG Instillation: In Bacillus Calmette-Guérin therapy, the drug is directly delivered into your bladder via a tube-like device. This comes into contact with a molecule in bladder tissue called fibronectin. Once BCG is introduced and activated, it alters antigen processing and helps stimulate immune cells.

• Immune System Activation: BCG mimics a pathogen-associated molecular pattern, prompting the immune system to treat it as an infection. This triggers innate immune sensors on bladder cells and immune cells, leading to the activation of cytokines and chemokines to recruit immune cells to the bladder. The activated immune cells are neutrophils, macrophages, dendritic cells, and T-cells.

• Adaptive Immune Response: Antigen-presenting cells, including dendritic cells, represent BCG and tumor antigens to T cells, activating tumor-specific immune responses. And CD4+ or helper T cells and CD8+ cytotoxic T cells become activated and expand. These cells are key to identifying and killing cancer cells.

• Effector Cells Kill Cancer: After immune cell activation, immune cells, such as natural killer cells (NK cells), neutrophils, and cytotoxic T lymphocytes, attack tumor cells directly or through the secretion of cytotoxic factors. BCG also boosts molecules such as TRAIL (TNF-related apoptosis-inducing ligand), which causes programmed cell death in cancer cells.

BCG immunotherapy is effective at targeting residual cancer cells, which is critical for your successful recovery. Any such leftover cancer cell can reestablish the disease, leading to cancer recurrence. Therefore, BCG immunotherapy can also help you reduce the possibility of bladder cancer recurrence.

How Should the Patient Prepare for the BCG Treatment?

Before BCG immunotherapy, the doctor will give you specific guidelines.

1. You must not drink caffeine-containing beverages.

2. Do not take diuretics (water pills) four hours before the procedure.

3. Ensure that you pass urine before the procedure because the urine might interfere with the drug.

What Happens During the BCG Immunotherapy?

• The doctor will administer local anesthesia before the treatment to make the patient comfortable and allow the procedure to be carried out quickly.

• Next, the doctor inserts a catheter into the urethra and injects BCG solution through it.

• The primary aim of this procedure is for the BCG solution to contact the cancer cells and kill them. Therefore, after the solution is injected, the doctor will remove the catheter and ask the patient to lie on their back, stomach, or sides for 15 minutes.

• When the procedure is complete, the patient can return home the same day, but should not pass urine for at least one hour.

• Hold the BCG solution in the urinary bladder for 2 hours, then urinate only afterward. Once the solution enters the bladder, the immune system attacks the cancer cells.

• The initial BCG treatment lasts 6 weeks and is known as induction therapy.

• If the doctor finds the treatment effective, the doctor might prescribe maintenance therapy. It is given once a week for three weeks in the third, sixth, and 12th months.

• Some people might undergo the treatment for three years.

Is BCG Immunotherapy Contagious?

The drugs used in BCG immunotherapy contain live tuberculosis bacteria that might be transmitted to others. However, the patient can follow the instructions below for six hours after every BCG treatment:

• Do not use public toilets.

• Drink plenty of water to dilute the urine.

• Sit down on the toilet while urinating to avoid splashing.

• After passing urine, the patient must add two cups of undiluted bleach to the toilet and wait 15 to 20 minutes before flushing.

• People with urinary incontinence or urine leakage must wash their clothes separately.

• If the patient wears an incontinence pad, soak the pad in bleach before discarding it in the trash.

What Are the Limitations and Benefits of BCG Immunotherapy?

Don’t get overwhelmed by the benefits that BCG immunotherapy can offer you. Also, keep a close eye on the roadblocks you might encounter.

Let’s Start With the Benefits First:

• The medicine is placed directly into the bladder, so it works exactly where the cancer cells are.

• Since BCG comes in direct contact with bladder cancer cells, it increases the chances of destroying remaining cancer cells after surgery.

• Unlike oral or intravenous treatments, BCH immunotherapy stays mainly in the bladder, reducing harm to other healthy organs.

• Because the drugs do not circulate widely in the bloodstream, fewer whole-body side effects are seen than with chemotherapy.

• BCG activates immune cells, helping your body fight cancer naturally rather than relying solely on drugs.

• It is very effective in lowering the chance of bladder cancer coming back, especially in early stages.

• BCG preserved the bladder by preventing the need for major surgery, such as bladder removal, in many cases.

Limitations of BCG Immunotherapy:

• Each person’s immune response is different, so BCG is not a guaranteed cure for all.

• It is not suitable for people with weak immune systems.

• It is not a one-time treatment; it requires weekly sessions for many weeks, followed by maintenance doses.

• Burning while urinating is common, along with fever, fatigue, and bladder irritation, which may occur after each session.

• If the side effects are severe, the doctor may have to stop or delay BCG immunotherapy.

• Regular hospital visits and monitoring are needed to ensure safety and effectiveness.

• BCG is mainly useful for early-stage bladder cancer and not for muscle-invasive or metastatic disease.

What Are Some of the Side Effects of BCG Treatment?

Side effects are commonly seen in the first 24 hours of BCG treatment.

The side effects of BCG treatment are listed below:

• Blood in the urine.

• Low-grade fever.

• Burning sensation while passing urine.

• Fatigue or tiredness.

• Urinating frequently, more than 8 times a day.

• Muscle pain.

• Pain in the joints.

The doctor will provide medication to manage these side effects or may ask the patient to take over-the-counter drugs to reduce fever and discomfort. The side effects of BCG treatment mostly subside within 72 hours, but the patient must consult the doctor if they persist.

The less common side effects of BCG treatment are listed below:

• Skin rash.

• High-grade fever.

• Vomiting and nausea.

• Loss of bladder control.

• Bladder spasm.

• Inability to pass urine.

• Urinary tract infections.

• Testicular inflammation.

• Ureteral obstruction.

• Thickening and scarring of the bladder muscles.

• Cell death or necrosis.

• BCG sepsis might occur if the BCG solution enters the bloodstream.

• Neutropenia (reduced white blood cell count).

• Hepatitis and BCG-induced hypersensitivity pneumonitis.

Can Bladder Cancer Recur After the BCG Treatment?

Bladder cancer can return after BCG immunotherapy, similar to other cancers. Studies have reported that cancer recurs in about 40 % of people who receive BCG treatment. However, an important point to note here is that cancer might recur, but does not progress or spread to other organs.

Early-stage cancer usually does not metastasize or spread to other organs, but people with low-grade cancer might develop other cancers in their lifetime. You may notice that the possibility of bladder cancer recurrence is comparatively less with BCG immunotherapy.

Conclusion:

BCG immunotherapy is becoming popular among doctors and patients because it is a conservative option to address early-stage bladder cancer. It works by directly activating the body’s immune cells within the bladder. It destroys the cancer cells, lowers the risk of recurrence, and often prevents the need for major surgery. The procedure takes 15 to 20 minutes, and the patient is spared surgical trauma.

So, you should not lose hope and must consult the doctor immediately for the BCG treatment. Talk to a health expert who will guide you in making the best decision for your bladder cancer.

Key Takeaways:

• Bacillus Calmette-Guérin immunotherapy is a great option in your fight against bladder cancer.

• BCG immunotherapy reduces the possibility of bladder cancer recurrence.

• Studies have reported that cancer recurs in about 40 % of people who receive BCG treatment.