Bladder
Guideline built on a systematic review of 153 studies across 4 KQs; read the strength and QoE grades, since there is no effect size here.
ASTRO Clinical Practice Guideline: RT for Bladder Cancer
ForBladder cancer, high-grade cT1 NMIBC through metastatic disease
TL;DRTMT recommended (strong, high QoE) as alternative to RC for select cT2-4aN0M0 MIBC; bladder-alone 5500 cGy/20 fx or 6400-6480 cGy/32-36 fx.
Elective pelvic nodes stay conditional: no validated RCT vs bladder-only RT, and bladder-only series show ~7% pelvic nodal recurrence. Prostate and proximal urethra are conditionally added for base/neck, T4 or prostatic urethral involvement. Investigational concurrent IO warrants caution with moderately hypofractionated whole-pelvis chemoRT or >400 cGy/fx.
In select cT2-4aN0M0 MIBC (solitary, <7 cm, no extensive CIS or hydronephrosis), this supports TMT with concurrent chemo as an alternative to RC; it gives only conditional, expert-opinion support to consolidative local therapy in cN2-3M0 disease after systemic response.
Elective pelvic nodes stay conditional: no validated RCT vs bladder-only RT, and bladder-only series show ~7% pelvic nodal recurrence. Prostate and proximal urethra are conditionally added for base/neck, T4 or prostatic urethral involvement. Investigational concurrent IO warrants caution with moderately hypofractionated whole-pelvis chemoRT or >400 cGy/fx.
Concurrent chemo is the preferred radiosensitizer (cisplatin ± 5-FU, 5-FU + mitomycin-C, low-dose gemcitabine), with neoadjuvant/induction systemic therapy for cT3-4 or N1-3 disease graded strong on low QoE. Perioperative chemo-IO and ADC-IO have no comparative TMT data, and concurrent checkpoint inhibitors stay investigational pending SWOG/NRG 1806.
TMT is graded a strong, high-QoE alternative to RC for select cT2-4aN0M0 MIBC, and for cN1M0 after neoadjuvant therapy TMT and RC sit side by side. A maximal, not necessarily visibly complete, TURBT precedes chemoRT, and MIBC relapse after TMT goes to salvage RC.
8 details 3 trials watching
Clinical practice guideline, not a trial. Systematic review of Ovid MEDLINE and Embase, January 2009 to November 18, 2024, yielding 153 studies; retrospective series limited to ≥65 pts (KQ1) and ≥100 pts (KQ2). Consensus by modified Delphi, threshold ≥75% agreement (≥90% for expert-opinion recs).
Adults (≥18 years) with bladder cancer treated with RT, across 4 KQs: bladder preservation, intact-bladder technique and dose, postoperative RT, noncurative RT. Out of scope: surgical management of MIBC, systemic-therapy specifics, intravesical therapy.
Preferred concurrent radiosensitizers: cisplatin ± 5-FU, 5-FU + mitomycin-C, or low-dose gemcitabine; carbogen and nicotinamide an alternative. Capecitabine ± mitomycin-C or single-agent 5-FU for pts ineligible for those agents.
Simulation and daily treatment supine with empty bladder and rectum; fiducials help delineate a tumor boost. 2 to 4 weeks from maximal TURBT to RT is typical, and post-TMT cystoscopy with biopsy follows at 8 to 12 weeks.
Caution, not absolute contraindication, for active inflammatory bowel disease, prior pelvic RT, or severely reduced bladder capacity. Elective nodal coverage is weighed against bowel toxicity.
Prior RTOG and NRG studies put the prostate in the field under 3-D CRT; the guideline narrows that to base/neck, T4 or prostatic urethral involvement. SWOG/NRG 1806 allowed bladder-only or bladder plus pelvic nodes, which the task force reads as equipoise on elective nodal coverage. Bladder-only series report ~7% pelvic nodal recurrence.
Search closed November 18, 2024 and excluded abstract-only reports. Histology guidance rests mostly on pure urothelial data, and ctDNA after TMT is not yet prospectively validated.
TMT is framed as curative treatment alongside RC within multidisciplinary shared decision-making, not a fallback for unfit pts. The guideline names access as the binding constraint: Black pts with MIBC are less likely to receive curative-intent cystectomy or chemoRT.
| Scenario | Recommendation | Strength | QoE |
|---|---|---|---|
| Select cT2-4aN0M0 MIBC | TMT as alternative to RC | Strong | High |
| High-grade cT1N0M0 NMIBC, T1 recurrence, cystectomy declined/ineligible | TMT or clinical trial | Conditional | Low |
| cN1M0 | TMT or RC after neoadjuvant/induction systemic therapy | Strong | Low |
| cN2-3M0, stable/responding after systemic therapy | Consolidative local therapy | Conditional | Expert opinion |
| Any TMT | Concurrent radiosensitizing systemic therapy | Strong | High (chemo); Moderate (carbogen/nicotinamide) |
| TMT, cT3-4 or N1-3 | Neoadjuvant/induction systemic therapy | Strong | Low |
| Bladder preservation | Maximal TURBT before chemoRT | Strong | Low |
| Setting | Dose-fractionation | Strength | QoE |
|---|---|---|---|
| Bladder alone, intact cT1-4N0M0 | 5500 cGy/20 fx or 6400-6480 cGy/32-36 fx | Strong | High |
| cT1N0M0 option | 6120 cGy/34 fx | Ungraded remark | n/a |
| Bladder + elective nodes, cT2-4N0M0 | Nodes + bladder 4000-4600 cGy, bladder boost to 6400-6480 cGy/32-36 fx | Strong | Low |
| Nodal alternative | Nodes 4000-4400 cGy/20 fx, bladder 5500 cGy/20 fx | Ungraded remark | n/a |
| Gross nodes, cT2-4N1-3M0 | Focal boost, tolerance-dependent; up to 6400-6480 cGy/32-36 fx | Conditional | Low |
| Escalation above 6400-6480 cGy | Not outside trial or multi-institutional registry | Strong | Moderate |
| Schedule | Daily RT, no mid-treatment break for cystoscopic assessment | Strong | Moderate |
| Recommendation | Strength | QoE |
|---|---|---|
| Whole bladder full dose, or reduced dose to uninvolved bladder + partial tumor boost (cT2-4N0-3M0) | Strong | Moderate |
| Elective pelvic nodes optional in cT2-4N0M0; higher-risk features (cT3-4, hydronephrosis, LVI, incomplete TURBT) | Conditional | Moderate |
| Prostate/proximal urethra for base/neck tumors, T4, or prostatic urethral involvement | Conditional | Moderate |
| IMRT/VMAT with daily CBCT to verify bladder volume | Strong | Low |
| Adaptive RT when coverage/OAR constraints or setup reproducibility fail | Conditional | Moderate |
ASTRO guideline from systematic review (153 studies) plus modified Delphi; output is graded recommendations, not outcomes. Elective nodal RT and adjuvant RT stay conditional.
- Elective pelvic nodal RT vs bladder-only RT in cN0 MIBC
- Concurrent checkpoint inhibitor added to TMT chemoRT n=520 · primary completion 2027-01 · phase 3 pembro + CRT vs CRT alone, N0M0 MIBCactive Chemoradiotherapy With or Without Atezolizumab in Treating Patients With Localized Muscle Invasive Bladder Cancer Phase 3n=475 · primary completion 2027-06 · phase 3 CRT ± atezolizumab in localized MIBC
- 5-fraction adaptive RT vs moderate hypofractionation recruiting Testing Shorter Duration Radiation Therapy Versus the Usual Radiation Therapy in Patients Receiving the Usual Chemotherapy Treatment for Bladder Cancer, ARCHER Study Phase 3n=486 · primary completion 2030-05 · phase 3 ultra-hypofx vs hypofx chemoRT, cT2-T3N0M0