Radiation Therapy for Bladder Cancer: An ASTRO Clinical Practice Guideline

Why clinicians should know about it

• Picked for Urology (top studies of the week, 20 September 2026): ASTRO guideline for bladder cancer radiation therapy
• Picked for Radiology, Radiation Oncology, Nuclear Medicine, Medical Physics and Imaging (top studies of the week, 20 September 2026): ASTRO bladder cancer RT guideline, directly relevant
• Picked for Radiation Oncology (paper of the day, 16 September 2026): ASTRO guideline, bladder RT recommendations

Abstract

PURPOSE: This guideline provides evidence-based recommendations addressing the indications for radiation therapy (RT) for bladder cancer in a variety of clinical settings, ranging from patients with localized disease to metastatic and symptomatic disease. METHODS: The American Society for Radiation Oncology convened a task force to address 4 key questions: (1) indications for bladder preservation with curative-intent RT, with or without systemic therapy, for patients with nonmetastatic bladder cancer; (2) appropriate RT techniques and dose-fractionation regimens for patients with intact, localized or node-positive bladder cancer; (3) indications, appropriate RT techniques, and dose-fractionation regimens for postoperative RT, with or without systemic therapy; and (4) indications and appropriate dose-fractionation regimens for RT to the bladder or sites of metastases for patients with metastatic or symptomatic bladder cancer being treated with noncurative intent. Recommendations are based on a systematic literature review and were created using a predefined consensus-based methodology with a system for grading evidence quality and recommendation strength. RESULTS: Multidisciplinary evaluation is encouraged for all patients. For select patients with cT2-4aN0M0 muscle-invasive bladder cancer, trimodal therapy (TMT) is an alternative to radical cystectomy. Concurrent radiosensitizing systemic therapy is recommended with TMT; neoadjuvant or induction systemic therapy is recommended for patients at higher risk of distant progression. RT to the whole bladder at full dose, or reduced dose to uninvolved bladder with a partial tumor boost, is recommended; elective nodal RT is conditionally recommended based on tumor characteristics. For patients with urothelial carcinoma who have (y)pT3-4 or (y)pN+ disease or positive margins postcystectomy, adjuvant RT is conditionally recommended for locoregional control. Intensity modulated RT with daily image guidance is recommended; target coverage goals and normal tissue dose guidance are provided. For patients with high-burden metastatic and locally symptomatic disease, or locoregional disease managed with noncurative intent, bladder-directed RT is recommended for local control and/or palliation. CONCLUSIONS: These evidence-based recommendations guide clinical practice on the use of RT for bladder cancer. Future studies will further refine the indications and role of RT in the management of these patients.

Abstract as published, via PubMed.