Dear Dr. Lamm,
Can B vitamins be taken with Oncovite?
Dear Friend,
The dose of B6 in Oncovite, 100mg, is very high, but B6 toxicity is very uncommon. Oncovite has the full compliment of B vitamins, so it would not
be necessary to take additional B vitamins, but it should not hurt if it is something you care to do.
Dear Dr. Lamm,
I have been treated for Tis with 6 instillations of BCG. At 3 months I had cysto that looked negative but a lot of irritation. FISH test came back 10 days later positive for CIS. I see in your protocol that actually the end of the 6 months that includes 3 maintenance instillations would more indicative of the presence or absence of CIS. Is this correct?
You are absolutely correct and should not be discouraged. It would obviously be "better" if your cysto, biopsy, cytology, and FISH were all negative at 3 months, but it commonly takes 6 for the complete response to occur. Patients who had a positive biopsy for CIS at 3 months in our SWOG maintenance BCG study had a 64% chance of being disease free at 6 months with the addition of 3 weekly BCG treatment.
Dear Dr. Lamm,
I am a urologist and have been using BCG for my patients with great success for many years. Recently a patient with bladder Ca required BCG. During the course of his treatment, he informed me that his dentist had started him on Cipro and Pen VK for a molar infection. What effect do concurrent antibiotic administration like Cipro, Sulfa , and Penicillins have on bladder BCG therapy?
Thank you for your input.
AG, MD
Dear Dr. AG., Your question is an excellent one. In the past we had used Isoniazid to reduce the side effects of BCG. European studies have addressed the question of both reduced side effects and efficacy. With isoniazid, a controlled Scandinavian double blind study found a reduction in side effects with no reduction in efficacy. The EORTC study found no reduction in side effects or efficacy with the addition of isoniazid. A recent study from France showed that ofloxacin reduced side effects, but not efficacy. Cipro and other fluoroquinolones are active against BCG and have the theoretical potential of reducing efficacy. Penicillin and sulfa are ineffective against BCG, and should have no effect. No reduction in efficacy has been documented in clinical trials with the addition of antibiotics, but a Dutch study did find reduction in immune response with concurrent antibiotic administration in an animal model. The bottom line, however, is that there does not seem to be any reduction in efficacy when antibiotics are given. I think this will be particularly true with the 3 week maintenance regimen due to the more intense immunization with this schedule.
Dear Dr. Lamm, I recently had a tumor removed. My doctor said it did not invade the bladder wall. He recommends BCG therapy. When I was younger I was exposed to TB (uncle & brother) I always show POS on TB tests. Is BCG still an option for me?
Your question is a good one. Most bladder tumor patients in the United States have not been exposed to TB or immunized with BCG to prevent tuberculosis. In other countries, both are much more common. The good news is that yes, you can receive BCG and should benefit from it.
In those with high risk disease such as carcinoma in situ, previous exposure may improve the results of BCG. Even those who have a very vigorous or hypersensitive response to PPD generally tolerate BCG well, but there is an increased risk of side effects. Should you have increased bladder symptoms or fever, chills and malaise, your doctor may want to reduce the dose of BCG. The schedule we use can be found here.
Dear Dr. Lamm,
I am currently being treated with BCG (per SWO protocol) for high grade TA/TB resected tumor at Cedars Sinai in Los Angeles. Concurrent with treatments, I am taking 7 - 100mg Polypheneon (Norin) caps 3 times per day, 3x7. Could you please tell me if you know of any conflict with BCG and Polyphenon or have any opinions about this?
Thank You,
D.A.
Dear D.A.,
To my knowledge there is no conflict between BCG and Polyphenone (Green Tea Extract). You should be aware that there have, unfortunately, been some severe liver failure cases associated with Green Tea Extract. The
FDA has recently sent an advisory to caution investigators using it. It is currently under evaluation at UCLA in a controlled trial comparing it
with Tarceva. That study is now being revised to eliminate the Green Tea extract.
Dear Dr. Lamm,
After three months since my 15th in a series of BCG treatments I am still having some side effects. There is a little urgency but most annoying is "night sweats" soaking my pillow. Cipro and Cellebrex and Pednzone for Cystitis have solved most of the side effects which in my case have been strong. I feel the sweats show a presence of TB down there somewhere, maybe the ejaculatory canal since my bladder seems fine. What do
you think or suggest. See my Dr. again on Jan 13th.
I have seen many patients who have continued night sweats after BCG (and some with night sweats who have never had BCG). I think you are absolutely correct: it is likely that BCG has set up housekeeping somewhere
in your body. It could be in your bladder, prostate, pelvic nodes, or just about anywhere. If it is not getting worse, it should not be a problem but if you have a major stress or disease that lowers your immune
system, you could develop a serious BCG infection. That can be effectively treated as long as you get the appropriate antibiotics.
Flaring of BCG infection has occurred a year or more after the last BCG treatment. I would be cautious with future BCG treatments. The good news is that the continued stimulation from BCG may provide the continued protection you need to prevent tumor recurrence.
My father (aged 66) suffers from a muscular-invasive bladder cancer (diagnosed early Dec. 2005) and after consulting with our physician, he will undergo a cystectomy early Feb. 2006. Our oncologist recommends 2 cycles of chemotherapy before surgery. What is your view on the recommended treatment? Would it be better to expedite the surgery (for 2-3 weeks or so) and postpone the chemo for later? And, finally, would a post-surgery immunotherapy vaccination (like BCG) decrease the chances of recurrence?
Thank You,
S.
Dear S,
The decision to use pre-operative or "neo-adjuvant" chemotherapy, like the decision to use post-operative or adjuvant chemotherapy for muscle invasive bladder cancer remains controversial and is best decided by individual patients in consultation with their doctors. That said, my recommendation would be to carefully consider your oncologist's recommendation.
His enthusiasm for neo-adjuvant chemotherapy is, like mine, probably based on the SWOG study that showed a 14% increase in survival at 5 years in those treated with MVAC. Interestingly, an equal improvement in survival
is found by performing a complete lymph node dissection at the time of surgery. Some doctors, therefore, would opt to do the complete lymphadenectomy and, if nodes are negative and the tumor is confined to the bladder, hold on chemotherapy. Generally two courses of chemotherapy
are well tolerated, but it is serious treatment.
Efforts are being made to reduce the side effects. For example, we have had a favorable experience with a less toxic combination: cisplatin, gemcitabine and
paclitaxel.
It would be appropriate to ask your urologist about his experience and philosophy regarding node dissection. Other questions would include the pros and cons of having a bladder substitution procedure for your father.
My personal preference in patients who wish to have a more normal body image and are medically fit is to use the Studer ileal bladder. It is not at all close to being as good as the bladder we are born with, but it does generally work. Night time incontinence, however, can be a problem.
If there is a good relationship with his doctors, it is generally best in a situation like this where there is no black and white answer to go with their recommendations.
Is it okay to continue taking MSM and omega 3 fish oils while having BCG treatments? If not when can you resume taking them? I have CIS and have had my first induction of BCG as well as one session of 3 maintenance BCG. I was taking MSM and omega 3 fish oils for mild arthritis before BCG. If I understand correctly, I think MSM is a component of DMSO which is used to treat interstitial cystitis. I don't want to do anything to hinder the full effect of the BCG. I wondered if MSM could improve the inflammation caused by the BCG and therefore reduce the response of the immune system. I wasn't as concerned about the omega 3 fish oils.
Thank you,
B.
Dear B.,
Some fish oil has high vitamin A content, and you need to be careful about overdosing on vitamin A if you are taking Oncovite. No problem with BCG -- vitamin A is reported to increase the efficacy. DMSO, if that is what you are taking, should also not be a problem.
Dear Dr. Lamm,
In the Physician's Presentation ( Bladder Cancer Immunotherapy: Progress and Current Limitations) slide 50 indicates the following: BCG immunotherapy is superior to chemotherapy and reduces progression, but 50-80% fail. This does not sound very good at all for someone with superficial bladder cancer. Can you please elaborate and provide details on the 50-80% failure rate?
Thanks,
M
Dear M.,
It is true that 50% or more of patients who receive BCG will eventually fail, that is, will have tumor recurrence. These figures include patients treated with what we now know is suboptimal therapy: BCG without
maintenance and BCG without Oncovite. In addition, we are referring to long-term follow up -- in some series as long as 15 years.
Here are the ballpark figures: Without treatment, 88% of patients who present with a bladder tumor will have recurrence within 15 years. With chemotherapy, there is a 6% reduction in 5 year recurrence. If that lasts, it would reduce 15 year recurrence with chemotherapy to 82%.
Suboptimal BCG treatment reduces 5 year recurrence compared with chemotherapy by about 20%, which if it lasts would reduce 15 year recurrence to 62%. We think we can do better, and need to do better, but these are our current numbers. The high failure rate is part of the reason I try to stress diet and lifestyle changes, as well as the importance of long term maintenance and vigilant follow up.
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