For appropriately selected patients with muscle-invasive bladder cancer, bladder preservation can be a curative treatment option, according to a new clinical guideline from the American Society for Radiation Oncology (ASTRO). The recommendations support trimodal therapy (maximal transurethral resection of bladder tumor followed by chemoradiation for bladder preservation) as an alternative to radical cystectomy 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 by Ballas et al in Practical Radiation Oncology.
Although bladder cancer incidence has declined modestly over the past decade, it remains the fifth most commonly diagnosed cancer among men in the United States, 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 has long been a standard curative treatment for muscle-invasive bladder cancer, typically combined with systemic therapy. Cystectomy may not be appropriate for some patients because of frailty or other health conditions, and in others, patient preference for bladder preservation.
Trimodal therapy preserves the bladder and may offer another curative approach for appropriately selected patients. It combines maximal resection of the bladder tumor, performed endoscopically 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 observed in patients undergoing 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, Program Director for the Genitourinary Radiation Oncology Program 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, Professor and Director of Radiation Oncology at Cedars-Sinai Medical Center. “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 cm, 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, including Black patients and those with lower socioeconomic status or Medicaid insurance; other racial and ethnic minorities; women; and older adults.
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 ASCO, the European Association of Urology (EAU), and the European Society for Radiotherapy and Oncology. It was endorsed by the EAU.
DISCLOSURE: For full disclosures of the guideline authors, visit practicalradonc.org.
