ENAfter a bladder tumour has been removed, the urologist mentions “BCG instillations” or the oncologist “immunotherapy”, and the family wonders whether this is the same thing and worth travelling to Germany for.
Bladder cancer immunotherapy in Germany means two different approaches for different stages: rinsing the bladder with BCG vaccine, and intravenous drugs that release the immune system’s “brake”. This page covers immunotherapy only: who each approach suits, how treatment runs, side effects and organisation. Surgery and chemotherapy are covered under bladder cancer treatment in Germany.
How the immune system can fight a bladder tumour
The immune system can destroy tumour cells, but tumours learn to hide from it, and immunotherapy helps it see them again. It either triggers a local inflammation in the bladder that draws immune cells in, or, like checkpoint inhibitors, removes the block holding them back. Checkpoints are “off switches” on immune cells, such as PD-1, which the tumour presses with its own protein, PD-L1; the inhibitor stops this, and the immune cells attack again.
Bladder cancer is one of the tumours in which immunotherapy has long been used. It does not replace surgery: it is part of a treatment plan approved by the multidisciplinary tumour board (Tumorkonferenz). Its use in other tumours is described under cancer immunotherapy.
BCG therapy for non-muscle-invasive bladder cancer
BCG therapy means instilling weakened tuberculosis-vaccine bacteria through a catheter directly into the bladder. It follows removal of the tumour through the urethra (TURBT) when the tumour is non-invasive but has a high risk of recurrence. “Non-invasive” means it has not grown into the muscle layer of the bladder wall.
Treatment starts with an induction course: under the German guideline, six instillations given once a week. If no tumour is found afterwards, maintenance cycles of three weekly instillations follow for one to three years, depending on the risk. It is an outpatient procedure without anaesthesia, and the solution stays in the bladder for about two hours. The urologist sets the exact schedule.
Burning on urination and a frequent urge to urinate are common after instillations, sometimes with a mild fever or a flu-like feeling: an expected reaction. Contact the doctor at once if a high fever lasts longer than two days or unusual symptoms appear outside the urinary tract. BCG supply in Europe is sometimes interrupted by production difficulties; the hospital plans the course around availability.
Checkpoint inhibitors for advanced bladder cancer
When the tumour has grown deep or spread, intravenous antibodies against PD-1 or PD-L1 are used. For urothelial cancer, which arises from the inner lining of the bladder, the EU has authorised, for example, pembrolizumab and nivolumab, which block PD-1, and avelumab, which blocks PD-L1. They are given as infusions every few weeks.
Avelumab is used as maintenance therapy if the disease has not progressed after platinum-based chemotherapy; pembrolizumab or nivolumab follows if that chemotherapy fails. As first-line therapy, the first drug treatment for advanced disease, pembrolizumab is combined with enfortumab vedotin, an antibody-drug conjugate carrying an anticancer agent straight to the tumour cell. After bladder removal with a high risk of recurrence, additional (adjuvant) nivolumab is possible. These are options, not a sequence: the choice depends on stage, kidney function and test results.
Doctors need the histology and stage in advance and, for some regimens, a PD-L1 test on tumour tissue; adjuvant nivolumab, for example, requires a certain level of this protein. So bring the paraffin tissue blocks and slides along. The US National Cancer Institute offers a patient overview of bladder cancer treatment, including immunotherapy.
Side effects and monitoring during immunotherapy
Intravenous immune drugs are tolerated differently from chemotherapy: hair does not fall out, but the released immune system may attack healthy organs such as the bowel, thyroid, liver, lungs or skin. Diarrhoea or breathlessness noticed late is dangerous because it may signal established bowel or lung inflammation, and severe lung inflammation can be life-threatening. Report any new symptom at once, not at the next infusion.
Blood tests, including thyroid hormones, are taken before each infusion, and CT scans at regular intervals show how the tumour responds. Patients receive a card with the hospital’s phone number for the time at home between courses. Immunotherapy does not help everyone: some patients respond, others do not, and this cannot be predicted in advance.
Frequently asked questions
Are BCG therapy and immunotherapy the same thing?
Not quite: BCG therapy is one type of immunotherapy, not the only one. BCG is instilled into the bladder, acts only there and treats non-invasive tumours after TURBT. Checkpoint inhibitors go into a vein, act throughout the body and are used when the tumour has grown deep or spread. The urologist and tumour board decide which fits.
How long does BCG therapy take?
With maintenance cycles, BCG therapy lasts from one to three years, though each instillation takes only a few hours. The induction course is six instillations given once a week, best spent near the hospital. Whether later cycles take place in Germany or at home, where an experienced urologist and the drug are available, is agreed in advance.
Does immunotherapy work for every patient?
No, and this cannot be predicted in advance: in some patients the tumour responds, in others it does not. Stage, histology and PD-L1 testing help to choose the regimen but do not guarantee a result. The response is checked regularly; if treatment is not working, the tumour board discusses other options.
How AlenMed arranges bladder cancer immunotherapy in Germany
AlenMed starts with the documents: discharge reports, the TURBT or cystectomy report, pathology report, paraffin blocks, and CT or MRI scans on disc. We translate them for urologists and oncologists at partner hospitals and arrange further tests if needed (see bladder cancer diagnostics). Partner hospitals include the urology departments of TUM Klinikum rechts der Isar, where Prof. Jürgen Gschwend heads the bladder cancer centre; University Hospital Essen, where Prof. Boris Hadaschik heads the uro-oncology centre; and Agaplesion Markus Krankenhaus in Frankfurt, whose chief physician, Prof. Georg Bartsch, has performed more than 500 cystectomies and is qualified in drug-based tumour therapy.
A BCG course means several weeks near the hospital, intravenous treatment repeat visits every few weeks, so agree in advance which follow-up can take place at home. We obtain the hospital’s cost estimate and visa invitation and arrange an interpreter. AlenMed’s office is in Munich; partner hospitals are all over Germany.
This material is for reference only and is not an offer. The immunotherapy regimen is decided by the doctor at an in-person consultation and by the tumour board.
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