Treating Stage Iv Bladder Cancer
These cancers have reached the pelvic or abdominal wall , may have spread to nearby lymph nodes , and/or have spread to distant parts of the body . Stage IV cancers are very hard to get rid of completely.
Chemotherapy is usually the first treatment if the cancer has not spread to distant parts of the body . The tumor is then rechecked. If it appears to be gone, chemo with or without radiation or cystectomy are options. If there are still signs of cancer in the bladder, chemo with or without radiation, changing to another kind of chemo, trying an immunotherapy drug, or cystectomy may be recommended.
Chemo is typically the first treatment when bladder cancer has spread to distant parts of the body . After this treatment the cancer is rechecked. If it looks like its gone, a boost of radiation to the bladder may be given or cystectomy might be done. If there are still signs of cancer, options might include chemo, radiation, both at the same time, or immunotherapy.
In most casessurgery cant remove all of the cancer, so treatment is usually aimed at slowing the cancers growth and spread to help people live longer and feel better. If surgery is a treatment option, its important to understand the goal of the operation whether its to try to cure the cancer, to help a person live longer, or to help prevent or relieve symptoms from the cancer.
Because treatment is unlikely to cure these cancers, many experts recommend taking part in a clinical trial.
How Should I Prepare For Bcg Treatment For Bladder Cancer
Prior to BCG treatment, your healthcare provider will give you a list of specific guidelines to help you prepare. In general, you should avoid caffeinated beverages and diuretics for four hours before your appointment. When you arrive for your procedure, you should pee to ensure that your bladder is empty.
Are There Any Possible Effects From The Treatment
9out of 10 people having BCG will develop some side effects these usually beginwithin 3-4 hours after treatment and may last 1-3 days.
You should tell your doctorat your next appointment if you have any of these symptoms.
- Somebladder discomfort – an irritation rather like a urine infection.
- Flu-likesymptoms which can last for 1-3 days after each treatment.
- Wantingto pass urine more often than usual or more urgently, which can last for two tothree days.
- Failureto complete the course of treatment due to discomfort in the bladder.
- Bloodor debris in the urine.
Drinking2 litres of fluid daily, unless advised otherwise, and avoiding tea/coffee for24 hours after treatment will help flush any remaining drug out of the bladderand may ease the above symptoms.
- Narrowing of the urethra following repeated use of a catheter.
- Inflammationwhich can affect various parts of the body .
- Persistentor severe pain after treatment, sometimes leading to removal of the bladder.
- Generalisedand possibly serious infection with the BCG bacteria needing treatment inhospital with powerful antibiotics. This is not TB and there is no risk ofcatching TB from the treatment.
Veryrarely – less than 1 person in every 100 – may experience more serious treatmenteffects.
Contact your GP/Nurse immediately if you have anyof the following:
- Urineis cloudy/offensive smelling
- HighTemperature over 38°C for 48 hours
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Why Do Some People Have Maintenance Therapy
Healthcare providers may advise patients who have certain types of non-muscle invasive bladder cancer to have maintenance therapy to attempt to keep the bladder cancer cells from growing back after treatment, which is called recurrence. Maintenance therapy may be recommended for patients who have a type of bladder cancer that is linked to a higher risk of recurrence.
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What Are The Side Effects
Some patients have difficulty completing long-term BCG therapy because of irritation in the bladder.2 To help with this irritation, the treatment frequency may be adjusted to give you a longer break between treatments. You may not notice any reaction after the first few BCG treatments. After the third treatment, patients usually start to experience bladder irritation pain or burning during urination, joint pain, fatigue, and flu-like symptoms that can last a few days. Most symptoms and side effects can be treated with over-the-counter pain medicines.
While BCG is a fairly common treatment for bladder cancer, every person has different experiences. It’s important to talk to your doctor about any questions or concerns you may have at any point during your treatment. Being mentally prepared for what to expect can help to reduce stress or uncertainty about treatment or help you think of additional questions for your healthcare team.
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Bladder Cancer And Its Symptoms
Bladder cancer is an invasive type of cancer that develops within the bladder. It affects the cells in the bladder and progresses slowly. When the cancerous cells spread to other parts of the body, it is referred to as metastasized bladder cancer.
The symptoms of bladder cancer are often vague or non-existent and so it can be hard to detect or diagnose. The symptoms depend on where the cancer is in the bladder i.e., whether it is contained only in the bladder or it has spread to other parts of the body.
The signs you should look out for include frequent urination, blood in the urine, pressure in your bladder and pain when urinating.
When cancer spreads out of the bladder, it is called metastasis. The most common place for metastasis of bladder cancer is in the bones, lymph nodes, liver and lungs. The symptoms of bladder cancer from its initial stage to the advanced stage include dizziness, difficulty in breathing, rashes, joint pain and in rare cases fever.
Is Bcg Treatment Contagious
Because BCG contains live bacteria, precautions are necessary to prevent it from being passed to others.
Patients should go to the bathroom sitting down to reduce splashing and wash their hands thoroughly after urinating. Pouring bleach into the toilet after use may also prevent contamination.
Once home, a patient should drink plenty of liquids and avoid sexual contact with others for 24 hours.
Research has shown that BCG may also reduce the risk of contracting a respiratory tract infection, giving your immune system a boost. However, precautions are still necessary to stay healthy.
The care team will talk to the patient about what to expect and provide instructions to follow at home.
Optimization Of The Use Of The Scarce Vials Of Bcg
As soon as BCG shortages began, different strategies were adopted at different levels, from improvements in BCG production to modifications of the recommended treatment.
Improving BCG Production
The production of BCG is not an easy matter. Due to the slow growth of the mycobacteria, any inaccuracy during the manufacturing process can lead to a large loss of time and money, as the BCG shortages have proven.22 For this reason, some researchers proposed optimizing BCG bulk production by modifying the growth in pellicles to the use of bioreactors29 or evaluating the possibility of extending the shelf life of the already manufactured BCG vials.30
Regulatory Issues/Favorable Policies
Variations in Clinical Guidelines Recommendations
For intermediate-risk NMIBC patients
- Intravesical chemotherapy must be used as a first-option treatment instead of BCG. Induction once a week for six to eight weeks plus a monthly maintenance schedule for one year.
- For second-line treatment, a one-third dose of BCG instead of full-dose BCG can be used. In that case, different patients can be treated the same day clustered in groups of three to avoid BCG wastage.
- Maintenance BCG can be omitted.
For high-risk NMIBC
Availability Of Data And Materials
The datasets supporting the conclusions of this article are available in the National Health Insurance Research Database, Taiwan .
Only citizens of the Republic of China who fulfill the requirements of conducting research projects are eligible to apply for the National Health Insurance Research Database . The use of NHIRD is limited to research purposes only. Applicants must follow the Computer-Processed Personal Data Protection Law and related regulations of National Health Insurance Administration and NHRI , and an agreement must be signed by the applicant and his/her supervisor upon application submission. All applications are reviewed for approval of data release.
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What Happens During Bcg Cancer Treatment
Before beginning BCG treatment, local anesthesia is given to numb the area and keep you comfortable. Next, your healthcare provider will place a catheter into your urethra and inject the liquid BCG solution into your bladder.
The BCG solution needs to come in contact with cancer cells to kill them. So, once the medication is injected, your healthcare provider will remove the catheter and ask you to lie on your back, stomach and both sides for 15 minutes each.
When the process is complete, youre free to leave your appointment. However, you should avoid peeing for at least one more hour.
How long do you hold BCG in your bladder?
Once the BCG solution is injected into your bladder, youll hold it for a total of two hours. After this point, youll be able to pee.
What does BCG do to the bladder?
When the BCG solution enters your bladder, your immune system cells begin to attack the cancer cells in your bladder.
BCG treatment schedule
The initial BCG cancer treatment occurs weekly for six weeks. This is called induction therapy.
If the treatment is working, your doctor may prescribe BCG maintenance therapy. Maintenance therapy is given once a week for three weeks at the three-, six- and 12-month marks. For some people, this may be continued up to three years.
Surgery After Bcg Failure
The EAU guidelines recommend cystectomy as the treatment of choice for CIS failing adequate BCG and as an option in other high-risk tumours.3 Similarly, the Canadian guidelines state that in patients with high-risk NMIBC with BCG failure, the option of radical cystectomy should be recommended and discussed with the patient .22 The guidelines also suggest that immediate cystectomy may be initially offered to patients with T1G3/T1HG and to patients with high-grade tumours with concomitant CIS or multiple recurrent high-grade tumours . The advantage of cystectomy in superficial tumours that failed BCG treatment is obvious. Tumour-specific survival is between 80% and 90% at 5 years, and thereby approaches the 5-year tumour-specific survival of patients with superficial bladder cancer.11
However, cystectomy for high-risk superficial disease is not only an invasive procedure linked to significant morbidity, but also has a number of other problems associated with it. When patients with NMIBC have a recurrence with invasive disease, a window of opportunity may be overlooked. For instance, in 62 patients with a high-grade recurrence and treated with cystectomy who had failed adequate BCG treatment, the 5-year disease-specific survival rate of progressive patients was only 38%, significantly lower than in those patients without invasive tumour. The authors identified the presence of a tumour in the prostatic urethra before cystectomy as a factor associated with shorter survival.48
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What To Expect Before Bcg Treatment
Before you are scheduled for BCG therapy, you will have to go through a screening test. This screening will determine whether you are eligible for BCG treatment or not. Factors considered during this screening test include the patients age, cancer type and stage, and overall health.
The doctor along with a radiation therapist will determine the best course of treatment for your condition and also ask you to avoid drinking too much fluid like water, juice, or caffeine.
If you are eligible, you will be given a date to schedule your treatment and will receive specific instructions on how to prepare. Once BCG is injected into the bladder, you will have to wait for 1-2 hours before urinating. This will allow the medicine to reach all the areas of the bladder.
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The success rate of bladder cancer treatment will vary depending on the age of the patient and the stage of the disease. Bladder cancer is a common and treatable disease, but bladder cancer treatment can be complex and challenging.
There are different treatment options available, each with different pros and cons. The best treatment option for you will depend on your situation and health.
We hope the information was helpful for you to understand what BCG treatment is, its symptoms, and what you can expect after the treatment. This method of treatment is considered a form of immunotherapy, which is an emerging form of cancer treatment.
Mechanism Of Action Of Bcg
The mechanism of action of bacillus Calmette-Guérin therapy is incompletely understood. Some early studies purported that an immune response against BCG surface antigens cross-reacted with putative bladder tumor antigens, and this was proposed as the mechanism for the therapeutic effect of BCG however, multiple subsequent studies refute this claim.
The most likely mechanism of action of BCG immunotherapy involves a combination of its direct effect on tumor cells along with the patients immune response to the therapy. These effects are summarized by Kawai et al into three categories: infection of cancer cells, induction of immune response, and antitumor effects.
The infection of cancer cells is mediated by the glycoprotein fibronectin, which allows the internalization of BCG, breakdown of proteins, and cellular changes that trigger the immune system. This is similar to the immunologic reaction that occurs in patients with tuberculosis. This immune response comprises specific cellular changes including surface receptor changes and release of various cytokines. Interferon is considered to be an important part of this process and has been used in the past to determine appropriate response to treatment. The immune response crescendos to antitumor activity in which cells recognize the cancer cells, target them for destruction, and subsequently decrease cancer burden.
The overall response to BCG is limited if the patient is immunosuppressed.
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Adverse Effects Of Bcg
Common adverse effects include cystitis, dysuria, malaise, fatigue, and a low fever . These can be managed by NSAIDS, phenazopyridine, and anticholinergics. If symptoms become intense or last longer than 24 hours, consider either delaying additional instillations until symptoms improve or reducing the dose.
In a review including 2602 patients treated with intravesical BCG instillation , the most common side effects were fever > 103ºF, hematuria, granulomatous prostatitis, pneumonitis and/or hepatitis, arthralgia, epididymitis, sepsis, rash, ureteral obstruction, bladder contracture, renal abscess, and cytopenia.
Early-onset BCG infection often presents as systemic manifestations. In contrast, delayed-onset infection presents as localized disease. Manifestations are as follows:
- Systemic manifestations occur when BCG disseminates outside of the genitourinary tract. They include sepsis syndrome, pulmonary issues from dyspnea, granulomatous hepatitis, osteomyelitis, reactive arthritis, monoarthritis, psoas abscess, and vascular complications due to mycotic aneurysms.
- Localized manifestations include cystitis, bladder contracture, granulomatous prostatitis, prostate abscess, epididymo-orchitis, testicular abscess, pyelonephritis, renal abscess, urethral stricture, and balanitis.
The AUA has noted the following with regard to BCG2:
Contributor Information and Disclosures
Fellow in Urologic Oncology and Minimally Invasive Surgery, University of Chicago Medical Center
What Happens During Treatment
A urinary catheter is inserted through your urethra and into your bladder. Then the BCG solution is injected into the catheter. The catheter is clamped off so the solution stays in your bladder. Some doctors may remove the catheter at this time.
You have to hold the medicine in your bladder. Youll be instructed to lie on your back and to roll from side to side to make sure the solution reaches your entire bladder.
After about two hours, the catheter is unclamped so the fluid can be drained. If the catheter was already removed, youll be asked to empty your bladder at this time.
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Practical Issues Of Bcg Administration
Some practical points need to be considered when using BCG for bladder cancer treatment. BCG manufacturers recommend evaluating the tuberculosis status of the patient with a PPD tuberculosis skin test before initiation of therapy, with some practitioners obtaining chest radiographs in all patients. This procedure has never proven necessary, probably owing to the exceedingly low incidence of tuberculosis in developed nations, where most bladder cancer patients do not meet the criteria for disease screening as recommended by the Centers of Disease Control and Prevention. In fact, patients with a positive PPD test without active disease should not be excluded from BCG therapy, as the presence of a systemic immune response might help augment the antitumour response as noted above. In addition, patients with a positive PPD result were shown to display adverse effect profiles during BCG treatment that are similar to patients with a negative test.
After Your Bcg Treatment
If thecatheter was left in the bladder during your treatment, the BCG will be drainedback into a bag before the catheter is removed.
If you wouldlike something to drink you can now do so.
Sex – youshould abstain from intercourse/oral sex for 2-3 days after each treatment. Theuse of condoms thereafter is advised and should continue to be used for severalweeks after your treatment has been completed.
Pregnancy -the effects on pregnancy are unknown. If you are planning to have children youshould discuss this with your doctor as female patients of child bearing ageare advised to use birth control during treatments and to wait at least 2 yearsbefore conceiving, longer if on maintenance treatment.
Breastfeeding is not advised when having BCG treatment
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Prediction Of Bcg Failure
What is the best method for predicting BCG failure? With complex interactions between mycobacteria, a host and a tumour, it is unlikely that one single parameter could be predictive for all patients, regardless of their immunological and tumour background.29 Although host, tumour and immunologic parameters can be useful, no single prognostic factor is capable of predicting a positive response. An excellent review by F. Saint30 adequately summarizes the knowledge on prognostic parameters of remission versus relapse following BCG therapy.
Substaging in T1 NMIBC may also be predictive of BCG failure.33 Van Rhijn, Van der Kwast and colleagues combined patients from Toronto and Rotterdam with primary high-grade NMIBC patients treated with BCG and found that substaging was a very significant predictor of BCG recurrence and progression when separating minimal and extensive pT1 high-grade NMIBC .