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BCG contraindications
I have recently (July 18, 06) had a transurethral resection to remove “noninvasivepapillary urothelial carcinoma, low-grade(i-iii)”.
I am scheduled to begin BCG therapy in 3 days from now, and continue for 6 weeks. My concern is that I had an allergic reaction to TB (tested +) test 34 years ago. Could this be an indicator of the severity of my reaction in the initial stages of this therapy? I have consulted with infectious disease docs
but none could give me a clear cut answer. My fear is that because of my allergy, the BCG treatment will induce a severe reaction. Surely there must be a way to anticipate trouble but none of the literature seems to take this into account. Are my fears groundless? If so, why. Thanks. -
13 Replies
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Wed Sep. 13. had second round of BCG. We still don’t have any idea what happened last Tues. CT Scan done but negative. Decided to proceed at the 1/3 dosage to see if I can get a reaction that can be interpreted as positive. Will keep all informed.
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I was good until Tues morning this week. I woke to severe nauseau and this progressed to vomiting. Scared, my wife called 911 and I was hospitalized and monitored thru Wed afternoon, then released. My scheduled BCG treatment for Wednesday was “postponed” by my doctor . He is mystified and cautious. I will report as events unfold.
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Glad to hear things went well. There’s info backing up the efficacy of a lower dose, saying it’s just as good. So…that’s good to know!
I hope the treatments are uneventful, but don’t let that stop you from posting anyway.
Wendy -
For those following this thread:
I finally began BCG treatments this morning, starting with 1/3 dose, and am happy to report that aside from the discomfort of the catheter insertion, and the inconvenience of having to employ super clean techniques, I had had NO adverse reaction yet. I am expecting some reaction, but I now think its going to be OK. I will definitely report here for the record, but only adverse or noteworthy events in the next 6 weeks.
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Thanks Wendy.
I have received a reply from Dr Lamm:
Dear Mr. P:
BCG has been given to many patients with a hypersensitive response to PPD.
PPD is the skin test for exposure to tuberculosis. More than 60% of
patients who receive intravesical BCG will convert to a positive PPD skin
test. There is some evidence that those who have a positive PPD or
convert to positive PPD have a lower risk of tumor recurrence when treated
with BCG. 90% of patients who receive percutaneous (through the skin) BCG
will convert to positive PPD, so I often add percutaneous administration
to increase the immune response.
Surprisingly, people who have had severe reactions to PPD generally
tolerate BCG. Nonetheless, there is an increased risk of side effects.
These effects can be reduced, if needed, be dose reduction of BCG.
Good luck and thanks for asking,
Don Lamm, MDI find this reply to be helpful in overcoming my reservations. Now if I can get the attention of my doc for adjusting or attenuating the dosage.
I wrote you a long reply, but the steam died out as I wrote it.
Whatever, I will try to be responsible and caring,
just like those that are helping on this forum. I do appreciate your input.
And I want to thank again, and again.
Slainte,
Phil -
P.S. I found the answer to your initial question, would BCG be contra-indicated in your case, having tested postive 34 yrs ago? From Michael O’Donnell at U of Iowa:
“This question has come up many times before. The answer is there is no reason not to get BCG therapy in the bladder. The patient should be aware, however, that the likelihood of getting reactions (side effects) sooner and more intense is greater. The way to deal with this is simply to dose reduce the BCG by one thirds (i.e from full dose to 1/3 to 1/10th to 1/30th etc) to maintain a tolerant side effect profile. Note: dose reduction may not be necessary at all in the majority of patients but is an option if side effects become problematic.
Michael O’Donnell, MD
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Hi Phil,
In no way do you come across as a fool, and funny thing about the internet, nobody using it seems old, at least to me!
Searching for answers and taking a pro-active stance regarding your diagnosis is a wise thing, though it’s certainly not for everyone. I think doctors prefer an informed patient these days. It’s a proven fact that people who are knowledgable about their diagnosis and involved in their treatment decisions do better than those who remain passive. That was a breast cancer study, but I’d think it would apply across the board…
I’m glad you have your sons to ask for input, also that you have a doctor who communicates with you! You’ve been through a lot these past few years, it must very scary. Maybe it’s not such a bad idea to postpone BCG until you and your doctor are sure it will help and not harm.
Good luck with everything and please keep us posted.
Wendy -
Wendy ,
I went to the web site you gave me and found that Drs. Kamat.A. and lamm,D. had presentented a paper in May suggesting antibiotic effectiveness in low grade tumor recurrences. Since I have unresolved queries because of my allergy, I have decided to postpone the BCG treatment.Your support and prompt response to my Q’s are greatly appreciated. I hope I can help someone else as well. Thank you, and God bless.
phil -
Thanks Wendy,
I would like to get the full paper, and now believe it will do no harm to delay the initial BCG steps until I’m sure it not a big mistake. I have to be careful not to act like an old fool.
I will also refer the paper to my family Doc and my sons for their input. I will continue to post here until a final conclusion is made. Hopefully the conclusion will be clearly made and others can benefit from it.
Thanks again,
Phil -
Hi Again Phil,
Your doctor has already given you the ‘new standard’ for recurrent, low grade TCC, a chemo wash after resection. BCG would be an even bigger and better treatment but is it really necessary, considering your tumors were low grade. Why wouldn’t he give this treatment time to work before moving on to BCG, I’m wondering, especially since you’re nervous about contracting TB and don’t know the answer to your initial question.
There was a recent article from France about using antibiotics along with BCG in order to allieviate and/or prevent bad side effects, I copy it below. If you and your doctor find it interesting enough you could buy the whole article. There has been other research that found antibiotics are actually good at preventing recurrence
( http://blcwebcafe.org/antibiotics.asp ):Improving Compliance of BCG Immunotherapy: Practical Approaches to Managing
Side-Effects
Pascal Rischmann, a,aCentre Hospitalier Universitaire de Rangueil, 1, avenue Jean Poulhès TSA50032, 31059 Toulouse Cedex 9, France
Available online 8 June 2006.Abstract
Adverse events (AEs) following intravesical bacillus Calmette-Guérin (BCG)
therapy are directly related to reduced compliance, leading to treatment
cessation and incomplete treatment. Dr Rischmann and his team designed a
prospective study to determine whether prophylaxis with ofloxacin could
improve the tolerance of BCG in the treatment of transitional cell carcinoma
(TCC) of the bladder. A secondary objective was to investigate the effect on
efficacy. The use of ofloxacin significantly decreased the incidence of
class 2 or higher AEs (moderate or severe) between instillations four and
six. With ofloxacin the percentage of class 3 AEs was also significantly
decreased between instillations one and nine. Although ofloxacin reduced AEs
involving the lower urinary tract, it did not prevent class 1 AEs.
Compliance to full BCG treatment was also improved. Ofloxacin did not appear
to impair the efficacy of BCG during 12 mo after treatment. The use of
prophylactic ofloxacin 200 mg given twice after BCG instillations appears to
be a simple and practical method of improving BCG tolerability yet
maintaining efficacy.
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This is the third surgical removal in the urogenital area. I have had prostate cancer 1998, a tumor removed 2004, from the ureter, and last year some small lesions of the bladder were resected by csystoscopic method. After the latest resection, the bladders was rinsed with a chemo wash and then the CT scan to verify that the ureters were clear. The BCG was suggested as a prevention therapy. I have talked with a virologist who reminded me that the bladder is considered “outside” the body, so the introduction of a low grade infection is not the same as entering the vascular system. And that a positive reaction to the infection will actully be an indication that the therapy is working. As for mitigation of the severity, I guess I’ll just have to take what comes, using antibiotics if the temperature gets too high.
Any suggestions will be appreciated, as I plan to go ahead tomorrow with the appointment to begin the therapy. My understanding is that the most severe reactions are after the third week, rather than right away. The rest of the literature suggests that this therapy is effective in reducing recurrence of even low grade tumors. -
I’m also curious, why BCG for a low grade tumor, was it high risk in some way? Large, over 4 cm? Is this your first bladder tumor?
Over-treatment can be just as bad as under-treatment. Have you had a second opinion?
About your concerns re:allergic reaction…you’d need to ask an expert. Try Dr. Lamm’s site:
http://www.bcgoncology.com/ He’s an expert on BCG.Wendy
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No your fears are not groundless. With my experiene of allergic reactions each time you are exposed to the allergen the reaction worsens. I guess it is all about benefit verses risk. I am curious why they are doing the BCG in the first place my understanding was that they don’t use BCG for a single papillary low grade carcinoma. Is this a recurrent tumor? Have you had a second opinion? I went to two different Uro’s and neither of them suggested BCG for a single papillary ta low grade (2 of 4) t.c.c.
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