New ASTRO Guideline Supports Bladder-Preserving Radiation Therapy for Select Patients

The American Society for Radiation Oncology (ASTRO) has issued its first clinical practice guideline focused specifically on radiation therapy across the spectrum of bladder cancer care. The recommendations support trimodal therapy as a curative alternative to bladder removal for appropriately selected patients and clarify the role of radiation therapy (RT) after surgery and in advanced disease. The guideline was published in Practical Radiation Oncology.

An estimated 85,000 U.S. adults will be diagnosed with bladder cancer in 2026, and approximately 18,000 will die from the disease. Radical cystectomy has long been a standard curative treatment for muscle-invasive bladder cancer, generally combined with systemic therapy. Trimodal therapy offers a bladder-preserving alternative that combines maximal transurethral tumor resection, RT and concurrent chemotherapy.

“Bladder preservation should be presented as a curative treatment option alongside radical cystectomy for appropriately selected patients with muscle-invasive bladder cancer,” said guideline task force chair Jason A. Efstathiou, MD, DPhil, FASTRO, of Mass General Brigham Cancer Institute and Harvard Medical School. “This guideline gives multidisciplinary teams practical guidance on patient selection and safe treatment delivery, with decisions guided by each patient’s disease, overall health and priorities.”

For patients with cT2-4aN0M0 muscle-invasive bladder cancer, the guideline recommends trimodal therapy as an alternative to radical cystectomy when appropriately selected. Favorable features include a solitary tumor smaller than 7 cm, predominant urothelial carcinoma, and absence of extensive carcinoma in situ or hydronephrosis. Patients should undergo cystoscopic assessment following treatment and continued surveillance for recurrence.

For patients at higher risk of recurrence after cystectomy—including those with pT3-4 disease, involved lymph nodes or positive surgical margins—adjuvant RT is conditionally recommended to improve locoregional control.

RT is also recommended for controlling disease or relieving symptoms such as bleeding and pain in patients with symptomatic metastatic disease or localized/locoregional disease not treated with curative intent. For low-burden metastatic disease responding to systemic therapy, bladder-directed RT is conditionally recommended.

“The role of radiation therapy in bladder cancer extends well beyond bladder preservation,” said guideline task force vice chair Leslie K. Ballas, MD, FASTRO, of Cedars-Sinai. She said the recommendations provide a framework for integrating RT after cystectomy and for symptom management in advanced disease.

For treatment delivery, ASTRO recommends intensity-modulated radiation therapy with daily image guidance. The guideline was developed from a systematic review of research published from 2009 through 2024 and in collaboration with the American Society of Clinical Oncology, European Association of Urology, and European Society for Radiotherapy and Oncology.