The American Society for Radiation Oncology convened a task force to address four questions on radiotherapy for bladder cancer, using a systematic review and graded recommendations.
For selected patients with cT2-4aN0M0 muscle-invasive bladder cancer, trimodal therapy — maximal transurethral resection followed by radiotherapy with concurrent radiosensitising systemic therapy — is an alternative to radical cystectomy. Neoadjuvant or induction systemic therapy is recommended for those at higher risk of distant spread. Radiotherapy may treat the whole bladder to full dose, or reduce dose to uninvolved bladder with a tumour boost; elective nodal radiotherapy is conditional. After cystectomy, adjuvant radiotherapy is conditionally recommended for pT3-4, node-positive or margin-positive urothelial carcinoma. Intensity-modulated radiotherapy with daily image guidance is the standard. For metastatic or symptomatic disease, bladder-directed radiotherapy is recommended for control and palliation. Multidisciplinary evaluation is encouraged for every patient.
The practical change is that bladder preservation should be discussed with every suitable patient, not only those unfit for cystectomy. In India, where many patients decline or are unfit for cystectomy and diversion, a formal trimodal pathway matters.
- Discuss every muscle-invasive bladder cancer at a multidisciplinary meeting including radiation oncology
- Offer trimodal therapy as an option to suitable patients, not only those unfit for surgery
- Best candidates typically have a single tumour, no hydronephrosis and complete resection
- Give concurrent radiosensitising chemotherapy with radiotherapy
- Consider adjuvant radiotherapy after cystectomy for pT3-4, node-positive or margin-positive disease
Why it matters
It moves bladder preservation from a fallback for the unfit to a standard option.
Don't overread it
Several recommendations, including elective nodal and adjuvant radiotherapy, are conditional.
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