Common Questions

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Common Questions

Bladder Cancer | Prostate Cancer

Bladder Cancer

"I have just been diagnosed with bladder cancer. Do I need BCG?"

Dr. Lamm: Not necessarily. While BCG is recognized as the most effective intravesical (within the bladder) treatment for bladder cancer, it is not the best for every patient. Patients who have a single tumor that is small, low grade, and without invasion, that is stage TA, have such a low risk that the cancer will later invade or spread that BCG is not generally needed.

Could it be used? Yes, but we prefer to give a single intravesical chemotherapy treatment at the time of surgery to prevent seeding or implantation of the tumor. If the tumor comes back or doesn't respond to chemotherapy, BCG can be given. We strongly recommend that all bladder cancer patients quit smoking. High dose vitamins, specifically Oncovite, two tablets twice a day is also recommended because it was found to reduce tumor recurrence by 40% and was most effective in low grade, low stage bladder cancer.

"I have been given 6 weeks of BCG for CIS, do I need more BCG, or maintenance BCG?"

Dr. Lamm: The use of maintenance BCG has been controversial for many years and was strongly criticized by investigators from Memorial Sloan Kettering and Washington University. I have advocated maintenance BCG for a long time because the risk of recurrence of bladder cancer is life long and the immune stimulation produced by BCG that prevents tumor recurrence decreases with time. In my opinion the question has finally been answered: maintenance BCG is clearly superior to 6 week induction BCG. The difficulty in proving maintenance BCG was superior was in part due to the fact that induction BCG is so very good!

In my Southwest Oncology Group study comparing induction and 3 week maintenance BCG that evaluated 550 patients randomized (a computer coin-flip) patients, maintenance BCG not only dramatically reduced long term recurrence, but also reduced disease progression. These results have been confirmed by meta-analysis, the highest form of "medical proof." Analysis by Sylvester, van der Meijden and I of nearly 5,000 patients confirmed that BCG reduced disease progression, but only if maintenance schedules were used. Similar meta-analysis by Bohle and Bock in Germany and Shelly et al in the United Kingdom show that maintenance BCG is superior, and BCG is superior to chemotherapy with Mitomycin C. (See Medical References, abstracts)

"My doctor has said I must have my bladder removed. Can we use BCG instead of cystectomy?"

Dr. Lamm: Cystectomy is the treatment of choice for bladder cancer once it has invaded the muscular wall of the bladder (Stage T2 to T3). For patients who are not medically fit for cystectomy, radiation therapy is recommended, and the results of radiation when combined with chemotherapy are good, even similar to those of cystectomy. BCG is not recommended for muscle invasive bladder cancer, but it has been used as a last resort when other options are not acceptable. Surprisingly, when muscle tumors that invade muscle are again resected transurethrally (repeat TURBT, removing the tumor through a scope inserted through the urethra) and no tumor or non-muscle invasive tumor is found, studies show that survival is actually better (82% at 5 years) in those who are treated with intravesical treatment than those treated with cystectomy (65%). These patients were not randomized, so patients undergoing cystectomy may have had worse disease.

Based on these data, however, it is hard to dogmatically say that patients who have no muscle invasion on repeat TURBT must be treated with cystectomy. My approach, which has been criticised for being too conservative, is to recommend cystectomy but support those who, after being informed, elect to keep their bladder. Some urologists recommend cystectomy for high-grade (G3), stage T1 (invading the lamina propria, the tissue between the surface cells and the bladder muscle) bladder cancer. The results of such treatment are good, but surprisingly again there are data, including complex computer modeling, that suggest that the result with BCG is even better, increasing 5 year survival from 82% to 91%. One third or more of patients with G3, T1 bladder cancer who have immediate cystectomy will be found to have muscle invasion. The incidence of muscle invasion with BCG treatment is only 12% at 4 years. If I had G3, T1 bladder cancer I would go with BCG using 3 week maintenance and very close follow up to be sure that tumor did not develop in the prostatic urethra or ureters.

"I had fever up to 102 with my 6th BCG treatment. Is it safe to get BCG after fever?"

Dr. Lamm: BCG is a live bacteria and can cause widespread infection and even death if not recognized and properly treated. Patients who have had bad reactions to BCG including BCG sepsis (blood stream infection, often with shock) often have had fever with previous treatments, so we must be very cautious and re-evaluate the need for BCG, the risk versus benefit ratio.

On the other hand, the good news is that patients who have a fever after BCG have a significantly reduced risk of tumor recurrence. If high-grade bladder cancer or CIS is present, my advice would be to proceed very cautiously with a reduced dose and schedule of BCG treatment. Rather than resume treatment at 3 months, it can be delayed until 6 or 9 months. When it is given I would start with a markedly reduced dose: 1/30th to 1/10th dose, and adjust the dose and schedule according to the side effects.

"What causes bladder cancer?"

Dr. Lamm: Bladder cancer is one of the first malignancies to be linked to carcinogens (cancer producing chemicals) in industry, but now an estimated 60% of bladder cancer is a result of smoking. Cigarette smoke has many known carcinogens and many are concentrated and excreted in the urine. Carcinogens react with DNA (the genetic material that regulates everything) forming "DNA adducts" that can lead to cancer. Interestingly, these DNA adducts can be found in the urine of smokers. Quitting smoking is one of the most important steps a bladder tumor patient can take. Studies now show that it reduces the risk of the tumor coming back and, more importantly, invading or spreading. Can't quit smoking? Ask your doctor to help, but in the meantime eat lots of fruits and vegetables: studies show that they reduce the DNA adducts in the urine of smokers.

"I quit smoking 20 years ago. I have no pain. How can I have bladder cancer?"

Dr. Lamm: The average interval between exposure to the carcinogen and the development of bladder cancer is 17 years. The risk of developing cancer is reduced but not eliminated by stopping. Bladder cancer, like early prostate cancer, kidney cancer, and testis cancer, generally does not cause pain.

Prostate Cancer

"My PSA is only 1.5. Do I still need to have my prostate examined?"

Dr. Lamm: PSA is a remarkably good tumor marker for prostate cancer when it is used correctly, but nothing in medicine or biology is 100%. It is not infrequent to have prostate cancer detected on digital rectal examination (DRE) where areas of increased firmness can be felt. It is important to have an experienced examiner such as a urologist do the exam if there is any question.

"My father and an uncle have prostate cancer, when should I have a PSA?"

Dr. Lamm: The American Urologic Association guidelines for PSA testing recommend screening begin at age 50 for the general population, and age 40 for African Americans and men with a family history of prostate cancer. Personally, having seen prostate cancer in men in their 30's, I believe PSA tests should be started even earlier. If tests are very low they need not necessarily be repeated every year.

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Created: 3/15/2005

The information available on and through the BCGOncology.com Web site is presented in summary form as a supplement to, and NOT a substitute for, the knowledge, skill, and judgment of qualified physicians and health care professionals. The information on BCGOncology.com has been obtained from sources believed to be accurate and reliable. However, BCG Oncology, PC makes no warranty as to the accuracy, reliability, or completeness of this information. Information accessed on or through BCGOncology.com is neither complete nor exhaustive and does not cover all disabilities, diseases, illnesses, and physical conditions or their management or treatment. Information accessed on and through BCGOncology.com is provided "AS IS" and without warranty, express or implied, including, but not limited to, any implied warranty of merchantability or of fitness for a particular purpose. View our terms of use for more information. Donald L. Lamm, MD is licensed to practice medicine in the state of Arizona, only.

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