ASTRO guideline: trimodal therapy is an alternative to cystectomy for selected muscle-invasive bladder cancer

The edition in brief

The American Society for Radiation Oncology recommends trimodal therapy — maximal resection, radiotherapy and concurrent radiosensitising systemic therapy — as an alternative to radical cystectomy for selected cT2–4aN0M0 muscle-invasive bladder cancer, with neoadjuvant or induction systemic therapy for those at higher risk of distant spread, IMRT with daily image guidance, conditional adjuvant radiotherapy after cystectomy for pT3–4, node-positive or margin-positive disease, and bladder-directed radiotherapy for palliation. In the TrueNTH Global Registry of 13,413 men, sexual function fell after every curative prostate cancer treatment, by a median 60% after prostatectomy and 40% after brachytherapy; 64–92% reported poor or absent erections at 12 months, and few used sexual aids. Among 61 patients with a clinical complete response to neoadjuvant chemotherapy on bladder-sparing surveillance, 28 had non-muscle-invasive recurrences (80% high grade), mostly managed with BCG, and these did not predict later muscle-invasive or metastatic relapse. A meta-analysis of 3,509 men found thulium fibre laser and conventional holmium enucleation of the prostate clinically comparable, with low-certainty evidence. The FDA recorded a supplement to Sun Pharma's generic tadalafil application; the record does not say what changed, and it is not a new indication. The pearl: ask about nitrates before prescribing a PDE5 inhibitor.