Frequently Asked Questions

BCG (Bacillus Calmette-Guérin) is a live attenuated strain of Mycobacterium bovis, originally developed as a tuberculosis vaccine. When instilled into the bladder, it triggers a local immune response that helps the body recognize and destroy cancer cells. BCG is the gold standard intravesical therapy for intermediate and high-risk non-muscle invasive bladder cancer (NMIBC).

• Limit fluid intake for 4 hours before the procedure to reduce urine volume • Empty your bladder completely just before the instillation • Do NOT take diuretics on the morning of treatment (consult your doctor) • Avoid caffeine and alcohol on the day of treatment • If you have a urinary tract infection (UTI), fever, or visible blood in urine, inform your doctor — treatment may need to be postponed • Avoid traumatic catheterization — if insertion is difficult, treatment should be deferred for at least 1 week

BCG treatment should be postponed in the following situations: • Active urinary tract infection (UTI) • Gross hematuria (visible blood in urine) • Traumatic catheterization during the procedure • Within 2 weeks of TURBT or bladder biopsy • Systemic illness or fever (>38.5°C) • Currently on antibiotics that may kill BCG (fluoroquinolones, anti-TB drugs) • Immunosuppressive therapy Typically, BCG should be started 2–4 weeks after TURBT to allow mucosal healing.

Fluoroquinolone antibiotics (e.g., ciprofloxacin, levofloxacin) should be avoided before BCG treatment as they have anti-mycobacterial activity and may reduce BCG efficacy. If you are prescribed antibiotics for a UTI, inform your urologist — BCG treatment should be deferred until the infection is cleared and antibiotics are completed. Isoniazid prophylaxis (sometimes used to prevent BCGitis) should only be given AFTER instillation, not before.

The procedure takes about 15–20 minutes: 1. A thin catheter is inserted through the urethra into the bladder 2. BCG solution (typically 1 vial in 50 mL saline) is instilled through the catheter 3. The catheter is removed 4. You are asked to retain the solution in your bladder for approximately 2 hours 5. During retention, you may be asked to change positions periodically (lying on each side, back, and stomach) to ensure full bladder contact 6. After 2 hours, you void the BCG solution into the toilet The procedure is performed in the outpatient clinic and you can go home afterward.

After voiding the BCG solution: • Add undiluted household bleach (200 mL) to the toilet and wait 15 minutes before flushing — this neutralizes the live bacteria • Drink plenty of fluids (2–3 liters) for 24–48 hours to flush the bladder • Wash your hands thoroughly after urinating • Sit down to urinate for 6 hours after treatment (to avoid splashing) • Avoid sexual intercourse for 48 hours after each instillation • Use a condom for 1 week after treatment if sexually active • Avoid pregnancy during the entire BCG treatment course • If symptoms persist beyond 48 hours or worsen, contact your doctor

Common side effects (occurring in 50–70% of patients) that are usually self-limiting: • Frequency and urgency of urination — typically resolves within 24–48 hours • Burning or discomfort during urination (dysuria) • Low-grade fever (<38.5°C) — usually resolves within 24 hours • Mild fatigue and malaise • Blood-tinged urine (mild hematuria) for 1–2 days • Flu-like symptoms for 24–48 hours These are signs that BCG is activating your immune system and are generally considered a positive indicator of treatment response.

Seek immediate medical attention if you experience: • High fever (>38.5°C) lasting more than 48 hours • Severe chills or rigors • Persistent gross hematuria (heavy blood in urine) • Severe pain that does not respond to over-the-counter painkillers • Joint pain or skin rash (may indicate systemic BCG reaction) • Symptoms of sepsis: confusion, rapid breathing, extreme fatigue • Inability to urinate • Symptoms lasting more than 72 hours without improvement These may indicate BCGitis or systemic BCG infection requiring anti-tuberculosis treatment.

The standard BCG protocol consists of: 1. Induction Phase (6 weeks): • Once weekly instillation for 6 consecutive weeks • Started 2–4 weeks after TURBT 2. Maintenance Phase (SWOG protocol, up to 3 years): • 3 weekly instillations at months 3 and 6 • Then 3 weekly instillations every 6 months for years 1–3 • Total: up to 27 instillations over 3 years For high-risk patients, 3 years of maintenance is recommended. For intermediate-risk, 1 year may be sufficient.

Recovery timeline after each instillation: • 0–6 hours: Retain BCG in bladder, then void • 6–24 hours: Most intense symptoms (frequency, urgency, mild fever) • 24–48 hours: Symptoms gradually improve for most patients • 48–72 hours: Most patients return to normal activities Most patients can return to work the next day, though some prefer to take the treatment day and following day off. Symptoms tend to be more pronounced in the first 1–2 instillations and may decrease with subsequent treatments, though some patients experience cumulative irritative symptoms during maintenance.

The recommended waiting period is 2–4 weeks after TURBT or ESD: • Minimum 2 weeks: To allow basic mucosal healing and reduce risk of systemic BCG absorption • Optimal 3–4 weeks: Recommended by most guidelines (AUA, EAU) • Maximum 6 weeks: Delaying beyond 6 weeks may reduce BCG efficacy Factors that may require longer waiting: • Deep resection with perforation risk • Large resection area • Persistent hematuria • Complicated post-operative course

The total treatment duration depends on risk stratification: • High-risk NMIBC: Up to 3 years - 6 weeks induction + maintenance every 3–6 months for 3 years - Total visits: approximately 27 instillations • Intermediate-risk NMIBC: 1 year - 6 weeks induction + maintenance for 1 year - Total visits: approximately 12–15 instillations Follow-up cystoscopy continues for 5–10 years even after completing BCG therapy, as bladder cancer has a high recurrence rate.

BCG treatment costs vary by region and healthcare system: • Hong Kong (Private): - Per instillation: HKD 5,000–10,000 - Full 3-year course: HKD 100,000–200,000+ - Includes consultation, catheterization, and BCG drug • Hong Kong (Public/Hospital Authority): - Significantly subsidized for eligible patients - Nominal charges apply per visit • Factors affecting cost: - BCG brand availability (global shortage may affect pricing) - Number of maintenance cycles required - Additional cystoscopy and biopsy costs - Complication management if needed Note: Costs are approximate and subject to change. Please consult your clinic for current pricing.

Alternative treatment costs (approximate, Hong Kong private sector): • Gemcitabine/Docetaxel intravesical: - Per instillation: HKD 3,000–8,000 - Full course (induction + maintenance): HKD 50,000–120,000 - Generally less expensive than BCG • Pembrolizumab (Keytruda) IV: - Per cycle (every 3 weeks): HKD 30,000–50,000 - Full course (up to 24 months): HKD 700,000–1,200,000 - May be partially covered by insurance • Nadofaragene firadenovec (Adstiladrin): - Currently limited availability in Asia - Estimated cost per instillation: USD 10,000–15,000 Insurance coverage varies significantly. Check with your provider for specific coverage details.

Insurance coverage depends on your plan type: • Hospital Authority (public sector): - BCG and standard treatments are covered - Waiting times may apply • Private medical insurance: - Most plans cover BCG as cancer treatment - Coverage for newer agents (Pembrolizumab, Nadofaragene) varies - Pre-authorization may be required - Check for annual/lifetime cancer benefit limits • Self-funded patients: - Payment plans may be available at private clinics - Some pharmaceutical companies offer patient assistance programs Recommendation: Contact your insurance provider BEFORE starting treatment to confirm coverage and obtain pre-authorization if needed.

Yes, most patients can maintain their normal work schedule during BCG treatment: • Treatment day: Plan for 3–4 hours at the clinic (including 2-hour retention time) • Next day: Most patients can work normally, though some prefer to rest • Tip: Schedule instillations on Friday afternoons so you have the weekend to recover However, if your job involves: • Heavy physical labor — take 24–48 hours off after each instillation • Immunocompromised patients contact — inform your occupational health team • Long commutes without bathroom access — plan accordingly for the first 24 hours

General exercise guidelines during BCG treatment: • Treatment day: Rest, avoid strenuous activity • 24–48 hours after: Light activities (walking) are fine • 48+ hours after: Resume normal exercise routine Specific considerations: • Swimming: Avoid for 48 hours after instillation (risk of contamination) • Cycling: May increase bladder irritation — avoid for 48 hours • Heavy weightlifting: Resume after 48 hours if no symptoms • Yoga/stretching: Generally fine after 24 hours Regular exercise is encouraged during the treatment course as it supports immune function and overall well-being.

There are no strict dietary restrictions, but the following recommendations may help: Before treatment: • Limit fluids 4 hours before instillation • Avoid caffeine and alcohol on treatment day During treatment course: • Stay well-hydrated (2–3L water daily, especially after instillation) • Eat a balanced diet rich in fruits, vegetables, and lean protein • Consider foods that support immune function (vitamin C, zinc) • Limit bladder irritants: caffeine, alcohol, spicy foods, artificial sweeteners Supplements to discuss with your doctor: • Vitamin D (may support immune response) • Probiotics (may help with treatment tolerance) • Avoid high-dose antioxidants during treatment (may interfere with immune activation)

Travel is possible but requires planning: • Short trips (1–2 weeks): Usually fine between instillation sessions • Long trips: Coordinate with your urologist to schedule around treatment dates • Air travel: Safe after 48 hours post-instillation Important considerations: • Carry a medical letter explaining your treatment (BCG may trigger TB screening) • Know the location of medical facilities at your destination • Maintain your follow-up cystoscopy schedule • Avoid travel to areas with limited medical access during active treatment • Bring sufficient medication for symptom management Do NOT skip scheduled instillations for travel — maintaining the treatment schedule is critical for efficacy.

Cystoscopy follow-up schedule for high-risk NMIBC: • First 2 years: Every 3 months • Years 3–4: Every 6 months • Year 5 onwards: Annually Additional monitoring: • Urine cytology: At each cystoscopy visit • Upper tract imaging (CT urogram): Annually for high-risk patients • Random bladder biopsies: If CIS was present initially Lifelong surveillance is recommended because: • Bladder cancer recurrence rate: 50–70% • Progression to muscle-invasive disease: 10–30% for high-risk • Early detection of recurrence allows less invasive re-treatment

BCG failure is classified into several categories: 1. BCG-Unresponsive: • Persistent or recurrent high-grade disease within 6 months of adequate BCG • This is the most concerning category • Options: Radical cystectomy (gold standard) or FDA-approved alternatives 2. BCG-Refractory: • Persistent disease at 6 months despite adequate BCG • No further BCG recommended 3. BCG-Relapsing: • Recurrence after achieving complete response • Early relapse (<12 months): Consider alternative therapy • Late relapse (>12 months): May benefit from BCG re-treatment BCG failure does NOT mean you have no options. Multiple effective alternatives exist including Pembrolizumab, Nadofaragene, and Gemcitabine/Docetaxel.

Long-term outcomes for high-grade NMIBC with appropriate treatment: • 5-year cancer-specific survival: 80–90% with proper management • 5-year recurrence-free rate with BCG maintenance: 60–70% • Bladder preservation rate: 70–80% at 5 years • Progression to muscle-invasive disease: 15–30% over 5 years Factors associated with better outcomes: • Complete response to initial BCG • Adherence to full maintenance protocol • Regular surveillance compliance • T1 without CIS has better prognosis than T1 with CIS • En bloc resection (ESD) may provide better staging accuracy Key message: With adherence to treatment and follow-up, most patients with high-grade NMIBC can achieve long-term bladder preservation and cancer control.