If you or a loved one has been diagnosed with non-muscle-invasive bladder cancer (NMIBC), your doctor may recommend a treatment called bacillus Calmette-Guerin (BCG) immunotherapy. NMIBC is a common early-stage form of bladder cancer. In this type, cancer cells are found only in the inner lining of the bladder and haven’t spread into the muscle wall.

BCG therapy is widely used for NMIBC, and it can be very effective in stopping or slowing the spread of bladder cancer. This article will cover how BCG immunotherapy works, when it’s used, and how well it works for treating NMIBC.

What Is BCG Therapy?

BCG therapy is a type of intravesical immunotherapy. “Intravesical” means that the treatment is placed directly into the bladder. “Immunotherapy” means that it activates the immune system to attack cancer cells.

BCG therapy, a type of immunotherapy given directly into the bladder, activates the immune system to attack cancer cells.

BCG therapy involves a liquid that contains a weakened version of the bacteria used in the tuberculosis vaccine. This bacterium, called Mycobacterium bovis, is strong enough to kick-start your immune system without making most people sick. People with weakened immune systems may be more at risk, so your healthcare team will carefully check you for any immune issues before recommending this type of treatment.

During therapy, the BCG solution comes in direct contact with the bladder’s inner lining. The immune-activating effects work best if your cancer hasn’t spread beyond the first inner layer.

How Is BCG Therapy Used in NMIBC?

BCG therapy is often recommended after transurethral resection of bladder tumor (TURBT). During this procedure, a surgeon removes any visible bladder tumors. When combined with TURBT, BCG therapy is considered the most effective treatment for NMIBC. BCG treatment is usually recommended for people with intermediate- or high-risk NMIBC.

A course of BCG therapy involves multiple visits. The schedule and length of treatment are based on your type of NMIBC.

The first phase, called induction therapy, typically lasts six weeks. The treatment is given once a week. After that, you may move to maintenance therapy, which is given every few weeks or months. Maintenance therapy usually lasts one year for people with intermediate-risk NMIBC and up to three years for those with high-risk NMIBC.

BCG therapy is given in courses over several weeks or months. It’s important to stick with the treatment for as long as recommended to lower the risk of cancer from coming back.

What Should You Expect During a BCG Treatment?

Before your first BCG treatment, your healthcare team will give you clear instructions. Usually, they’ll ask you not to drink anything for a few hours before your appointment. This helps ensure your bladder is empty and ready for the treatment. Your provider will also make sure you don’t have a urinary tract infection.

At the start of the procedure, your provider will apply local anesthesia (numbing medicine) around the urethra (the opening where urine leaves the body) to reduce any discomfort. Next, they’ll gently insert a thin, flexible tube called a catheter through the urethra into your bladder. The BCG liquid is then delivered through the catheter and into your bladder. After the liquid is in, the catheter is removed.

You’ll be asked to hold the liquid in your bladder for about two hours. It’s especially important not to pee for at least the first hour so the medicine can stay in contact with your bladder lining and activate your immune system.

What Happens After BCG Treatment?

For the first six hours after a BCG treatment, you’ll need to protect others from coming into contact with the live bacteria in your urine. This is especially important for people with weakened immune systems, who may be more at risk of infection. Follow these safety steps:

• Don’t use public toilets.
• Drink lots of fluids to help flush the bacteria out of your bladder and dilute your urine.
• Sit down to urinate to reduce splashing onto your skin or surroundings.
• Add 2 cups of undiluted bleach to the toilet after peeing, and let it sit for 15 to 20 minutes before flushing.
• Wash your hands thoroughly with soap and water each time you use the bathroom.
• Avoid sex for 24 hours after each treatment. Use condoms during the full course and for a week after your last dose to avoid spreading bacteria to your partner.

What Are the Potential Side Effects of BCG Therapy?

Many people experience mild side effects within 24 hours after BCG therapy. These side effects are usually temporary and can be managed with over-the-counter or prescribed medications. Common side effects include:

• Flu-like symptoms, such as low fever, muscle and joint pain, and tiredness
• A burning sensation or discomfort when peeing
• More frequent or urgent peeing
• A small amount of blood or debris in your urine

Some of these may be similar to symptoms of bladder cancer.

Rare but Serious Side Effects

In about 1 percent of cases, BCG bacteria can cause a serious infection similar to tuberculosis. Call your healthcare provider right away if you develop any of the following symptoms:

• High fever (over 101.3 degrees Fahrenheit) for more than 48 hours
• Chills or joint or muscle pain
• Blood in phlegm, coughing, or vomiting
• Rash
• Extreme tiredness
• Unintentional weight loss
• Sudden loss of appetite

Some people may not be able to tolerate BCG therapy because of side effects. Other treatment options include intravesical chemotherapy. Talk with your healthcare team if you’re having trouble with side effects from BCG therapy and want to discuss other options.

How Effective Is BCG Therapy?

Research shows that about 60 percent of people whose NMIBC responds to BCG therapy will still be cancer-free for more than five years. To help lower the risk of cancer coming back, it’s important to follow the maintenance BCG schedule that your cancer care team recommends.

However, BCG therapy doesn’t work for everyone. Some studies show that 30 percent to 50 percent of people with NMIBC have cancer that doesn’t respond to this treatment. It can mean that tumors don’t shrink, new tumors appear, or the cancer returns during or after treatment.

About 50 percent to 70 percent of people have NMIBC that responds to BCG therapy.

If your cancer doesn’t respond or comes back, your healthcare team will talk with you about other options. These might include:

• A second round of BCG therapy
• Radical cystectomy (surgery to remove the bladder)
• Newer treatments, such as immunotherapy and drugs, which may work well for BCG-unresponsive bladder cancer

Your care team will help you weigh the pros and cons of each option and choose what’s best for your situation. Read more about what happens when bladder cancer is refractory, or resistant to treatment.

Talk With Others Who Understand

MyBladderCancerTeam is the social network for people with bladder cancer and their loved ones. On MyBladderCancerTeam, members come together to ask questions, give advice, and share their stories with others who understand life with bladder cancer.

Have you or a loved one received BCG therapy for NMIBC? Do you have tips for others who will receive this treatment? Share your experiences in the comments below, or start a conversation by posting to your Activities page.