ASTRO issues its first clinical guideline on radiation therapy for bladder cancer

For appropriately selected patients with muscle-invasive bladder cancer, preserving the bladder can be a curative treatment option rather than removing it, according to a new clinical guideline from the American Society for Radiation Oncology (ASTRO). The recommendations support trimodal therapy as an alternative to bladder removal and provide guidance on the use of radiation therapy after surgery and for patients with metastatic or symptomatic disease. The guideline, ASTRO’s first focused specifically on radiation therapy across bladder cancer care, was published in Practical Radiation Oncology, ASTRO’s clinical practice journal.

Although bladder cancer incidence has declined modestly over the past decade, it remains the fifth most commonly diagnosed cancer among U.S. men, occurring about four times more often in men than in women. In 2026, an estimated 85,000 U.S. adults will be diagnosed with bladder cancer, and approximately 18,000 will die from the disease.

Radical cystectomy, or surgical removal of the bladder, has long been a standard curative treatment for muscle-invasive bladder cancer, typically combined with systemic therapy. The operation also requires creating a new way for urine to leave the body. Cystectomy may not be appropriate for some patients because of frailty or other health conditions, while others may prefer to preserve their bladder.

Trimodal therapy offers another curative approach for appropriately selected patients while preserving the bladder. It combines three treatments: maximal resection of the bladder tumor, which is an endoscopic procedure performed through the urethra, followed by radiation therapy with concurrent chemotherapy. Long-term studies and observational comparisons suggest that carefully selected patients treated with trimodal therapy can achieve cancer outcomes similar to those seen with radical cystectomy, with the potential to retain a functioning bladder.

“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, a radiation oncologist at Mass General Brigham Cancer Institute and professor of radiation oncology at 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.”

“The role of radiation therapy in bladder cancer extends well beyond bladder preservation,” said guideline task force vice chair Leslie K. Ballas, MD, FASTRO, a radiation oncologist at Cedars-Sinai. “The recommendations clarify when radiation therapy may improve local control after cystectomy and how it can be used to relieve or prevent symptoms for patients with advanced disease, giving multidisciplinary teams a clear framework to integrate radiation throughout bladder cancer care.”

Key recommendations are summarized below; the full guideline provides detailed guidance on patient selection, treatment planning, dosing and follow-up. Multidisciplinary evaluation and shared decision-making are encouraged throughout care.

Bladder Preservation with Curative-Intent Radiation Therapy

• For appropriately selected patients with cT2-4aN0M0 muscle-invasive bladder cancer, trimodal therapy is recommended as an alternative to radical cystectomy. Favorable features for bladder preservation include a solitary tumor that is smaller than 7 centimeters, predominant urothelial carcinoma and no extensive carcinoma in situ or hydronephrosis.

• Trimodal therapy should include maximal transurethral resection of the bladder tumor followed by radiation therapy with concurrent radiosensitizing systemic therapy. Neoadjuvant or induction systemic therapy is also recommended for patients at higher risk of developing metastases. Patients receiving trimodal therapy should undergo cystoscopic assessment after treatment and continued surveillance for recurrence.

Radiation Therapy Following Cystectomy

• Adjuvant radiation therapy is conditionally recommended to improve locoregional control for patients at higher risk of recurrence after cystectomy, including those with pT3-4 disease, involved lymph nodes or positive surgical margins. Having a neobladder does not preclude postoperative radiation therapy.

• When postoperative radiation is used, treatment generally should begin after adequate surgical recovery and completion of any planned adjuvant chemotherapy. Treatment typically includes the cystectomy bed and pelvic lymph nodes, with modifications for selected patients based on surgical margins, urinary reconstruction and risk of bowel toxicity.

Advanced and Symptomatic Disease

• Bladder-directed radiation therapy is recommended to control disease or relieve symptoms such as bleeding and pain for patients with symptomatic metastatic disease and for patients with localized or locoregional disease who are not receiving curative treatment.

• For patients with low-burden metastatic disease that responds to systemic therapy, radiation therapy to the bladder is conditionally recommended. Radiation therapy directed at a limited number of metastatic sites also may be considered.

• Radiation therapy to the bladder is not recommended for patients with asymptomatic high-burden metastatic disease. Palliative radiation is recommended for metastatic sites that are symptomatic or likely to cause symptoms.

Radiation Treatment Planning and Delivery

• The guideline provides recommended dose and fractionation schedules for curative and palliative treatment, as well as guidance on when to treat the whole bladder, boost the tumor or include pelvic lymph nodes. Intensity-modulated radiation therapy with daily image guidance is recommended.

• The guideline also identifies persistent disparities in bladder cancer care. Access to multidisciplinary evaluation and bladder-preserving treatment may be limited in underserved or rural communities. The task force calls for broader access to evidence-based treatment and greater inclusion of populations that have historically been underrepresented in bladder cancer research.

About the Guideline

“Radiation Therapy for Bladder Cancer: An ASTRO Clinical Practice Guideline” was developed by a multidisciplinary task force of radiation, medical and urologic oncologists, as well as a medical physicist and patient representative. The recommendations are based on a systematic review of research published from 2009 through 2024. The guideline was developed in collaboration with the American Society of Clinical Oncology, the European Association of Urology (EAU) and the European Society for Radiotherapy and Oncology. It was endorsed by the EAU.

ASTRO’s clinical guidelines are intended as tools to promote appropriately individualized, shared decision-making between physicians and patients. None should be construed as strict or superseding the appropriately informed and considered judgments of individual physicians and patients.

ABOUT ASTRO
The American Society for Radiation Oncology (ASTRO) is the world’s largest professional society dedicated to advancing radiation medicine, with 11,000 members including physicians, nurses, physicists, radiation therapists, dosimetrists and other professionals who work to improve patient outcomes through clinical care, research, education and advocacy. Radiation therapy is integral to 40% of cancer cures worldwide, and more than one million Americans receive radiation treatments for their cancer each year. For information on radiation therapy, visit Speed of Light – The ASTRO Foundation. To learn more about ASTRO, visit our website and press room and connect with us on social media.