The American Society for Radiation Oncology issued an evidence-graded guideline on radiotherapy across bladder cancer, from localised to metastatic disease.
It recommends multidisciplinary evaluation for every patient. For selected cT2–4aN0M0 muscle-invasive disease, trimodality therapy (maximal transurethral resection, then radiotherapy with concurrent radiosensitising chemotherapy) is an alternative to radical cystectomy, with neoadjuvant or induction systemic therapy for those at higher risk of distant spread. It recommends full-dose whole-bladder radiotherapy or a partial tumour boost, intensity-modulated radiotherapy with daily image guidance, and conditionally recommends adjuvant radiotherapy after cystectomy for pT3–4, node-positive or margin-positive disease. Bladder-directed radiotherapy is recommended for palliation.
Many patients with muscle-invasive disease are still offered only cystectomy, often without meeting a radiation oncologist. A guideline recommendation for trimodality therapy, and for multidisciplinary review of every patient, makes bladder preservation a choice that must be discussed. Selection matters: unifocal tumours, complete resection and no hydronephrosis or carcinoma in situ do best.
- Refer every muscle-invasive bladder cancer to a multidisciplinary team including radiation oncology
- Discuss trimodality therapy alongside cystectomy with suitable patients
- Use concurrent radiosensitising chemotherapy with radiotherapy
- Plan lifelong cystoscopic surveillance after bladder preservation
- Consider adjuvant radiotherapy after cystectomy for high-risk pathology
Why it matters
Bladder preservation is now a guideline-endorsed option, so offering only cystectomy leaves out a recommended choice.
Don't overread it
Trimodality therapy is for selected patients; the guideline does not claim it is superior to cystectomy.
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