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Public Science Insights: Bladder cancer and the use of Bacillus Calmette–Guérin (BCG) Vaccine

Posted Tue, Mar, 28,2017

Bladder cancer is the fourth most common cancer in men and the eighth most common in women. Most of these cancers are superficial and confined to the bladder inner wall. The most usual complaints associated with this type of cancer are blood or blood clots in the urine (hematuria), pain during urination (dysuria), urinating small amounts frequently (frequency), and frequent urinary tract infections (UTIs).

Blood in the urine is the most frequent and is usually an early alarming symptom of bladder cancer. For this reason, hematuria should be taken seriously and investigated fully. This will lead to early detection of cancer at a stage where it is localized to the cells that line the inside of the bladder. All people with complaints suspicious of bladder cancer will receive a cystoscopy. This is a thin tube with a camera and light on the end passed through the patient's urethra into the bladder. A jelly containing anesthetic is squeezed into the opening of the urethra to make the procedure less uncomfortable. If the doctor sees an abnormal area in the lining of the bladder, he/she will take a piece of tissue (biopsy) to be examined under the microscope for cancer cells.

Early surgery with the removal of superficial tumors through a scope is the preferred treatment. The main operation is TURP (transurethral resection of a bladder tumor). In this operation, the specialist passes a scope through the urethra and eliminates the tumor using devices that are passed through the scope. Unfortunately, despite full removal, cancer may return in 48% to 70%, and progression occurs between 7% and 40% of the patients. This has led to consideration of adjuvant chemotherapy given through a tube in the bladder or more recently the instillation of Bacillus Calmette-Guérin (BCG) in the urinary bladder.

BCG is a vaccine used to prevent tuberculosis (TB). It is a weakened form of Mycobacterium bovis. It has been in use as a vaccine for almost a century and has shown to be effective in bladder cancer for almost four decades. It is not exactly known how it works but scientists believe it is most likely through stimulation of anti-tumor immunity leading to the destruction of cancer cells. BCG instillation has been shown to delay the time to the first recurrence after TURBT and to reduce the risk of progression to muscle-invasive disease. Like chemotherapy, it is given through a tube in the bladder with the treatment being repeated once weekly for six weeks. The patient will be asked to retain the fluid in the bladder for one hour with 15 mintues lying on the back, 15 minutes lying on the tummy, and 15 minutes lying on each side. In some cases, the course is followed by once a week for three weekly instillations at 3, 6, 12, 18, 24, 30, and 36 months.

Although BCG can lead to a number of side effects, serious complications are rarely reported. Since the drug is left in the bladder most of the complications are of local nature including pain on passing urine, blood in urine, and the urge to pass urine. Flu-like symptoms and fever, as well as joint pains, were described. Occasionally persistent fever, joint pains, and cough may indicate hypersensitivity or spread of infection to other body sites. In such cases, treatment with drugs used for tuberculosis and corticosteroids may be prescribed by the doctor.

Overall, when BCG is given in appropriate courses the response rate can reach 55-65% for Ta/T1 tumors and 70-75% for carcinoma in Situ (CIS). The potential benefits of intravesical BCG seem to outweigh the risk of serious complications.

Dr. Fatehi Elzein, is author of the recently published paper Disseminated Mycobacterium bovis Infection Complicating Intravesical BCG Instillation for the Treatment of Superficial Transitional Cell Carcinoma of the Bladder, available for download now in Clinical Medicine Insights: Case Reports.

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