First ASTRO Guideline Backs Bladder-Sparing Treatment for Some Patients

On Sept. 17, 2026, the American Society for Radiation Oncology (ASTRO) published its first clinical practice guideline on radiation therapy for bladder cancer. The guideline recommends that carefully selected patients with muscle-invasive bladder cancer be offered a bladder-sparing approach called trimodal therapy as an alternative to surgery to remove the bladder.

The guideline appeared in the journal Practical Radiation Oncology. ASTRO developed it with the American Society of Clinical Oncology, the European Association of Urology (which endorsed it) and the European Society for Radiotherapy and Oncology. The task force, chaired by Dr. Jason A. Efstathiou of Mass General Brigham, included cancer specialists, a medical physicist and a patient representative.

"Bladder preservation should be presented as a curative treatment option alongside radical cystectomy," Efstathiou said in ASTRO's announcement.

Who It's For

The central recommendation applies to people with muscle-invasive bladder cancer, meaning the cancer has grown into the thick muscle wall of the bladder, that has not spread to lymph nodes or distant organs. In staging terms, this is cT2 to cT4a, N0, M0 disease.

The long-standing standard has been radical cystectomy, an operation that removes the bladder and requires a new way to store or pass urine, such as a neobladder (a new bladder built from intestine) or a urostomy bag. Trimodal therapy instead combines surgery through the urethra to remove as much tumor as possible, radiation to the bladder, and systemic therapy (usually chemotherapy) given during radiation to make cancer cells more sensitive to it.

The guideline lists features that make someone a better candidate for bladder preservation: a single tumor smaller than 7 centimeters, cancer that is mainly urothelial carcinoma (the most common type of bladder cancer), and no widespread carcinoma in situ (flat, early cancer cells lining the bladder) or hydronephrosis (swelling of the kidney caused by a blocked flow of urine).

For patients at higher risk of the cancer spreading, the guideline also recommends systemic therapy before trimodal therapy begins. CURE has covered the benefits and risks of bladder-conserving therapies.

What the Guideline Recommends Beyond Bladder Preservation

The guideline also addresses other situations where radiation may play a role:

• After bladder removal: For patients whose surgery showed a higher risk of the cancer returning in the pelvis, such as cancer that had grown outside the bladder (pT3 to pT4), cancer in the lymph nodes or cancer at the edge of the removed tissue (positive margins), radiation after surgery is "conditionally recommended" to improve control of the cancer in that area. Having a neobladder does not rule out this radiation.
• Symptoms from advanced cancer: Radiation to the bladder is recommended to control the cancer or ease symptoms such as bleeding or pain in people with metastatic disease that is causing symptoms, and in people whose localized cancer is not being treated with the goal of cure.
• Limited metastatic disease: For people with a small number of metastases that respond to systemic therapy, radiation to the bladder is conditionally recommended. Radiation to a limited number of metastatic sites may also be considered.
• Not recommended: Radiation to the bladder is not recommended for people with widespread metastatic disease that is not causing symptoms.

On technique, the guideline recommends intensity-modulated radiation therapy, which shapes the dose closely around the target, with daily imaging before each treatment.

What It Requires After Treatment

The guideline calls for a cystoscopy (a camera exam of the bladder) after trimodal therapy to check the response, followed by ongoing surveillance, because cancer can return in a preserved bladder.

What's Still Unknown

A "conditional" recommendation means the panel judged that benefits likely outweigh harms for many patients but that the evidence is less certain or that individual circumstances matter more. The guideline was built on a systematic review of studies published from 2009 through 2024, and several areas, including newer combinations of radiation with other drugs and shorter radiation schedules, are still being tested in clinical trials.

The authors also note that patients in rural and underserved areas often have limited access to bladder-preserving treatment and multidisciplinary teams.

What It Means for You

According to ASTRO, about 85,000 adults in the U.S. are expected to be diagnosed with bladder cancer in 2026, and about 18,000 are expected to die of the disease. For people with muscle-invasive disease who meet the selection criteria, the guideline makes clear that keeping the bladder is a recognized curative option, not only a fallback for those who cannot have surgery. Meeting with a surgeon, a radiation oncologist and a medical oncologist before deciding can help.

Questions to Ask Your Care Team

• Do my tumor's size, type and stage make me a candidate for trimodal therapy?
• Can I meet with both a urologic surgeon and a radiation oncologist before deciding?
• What follow-up exams would I need if I keep my bladder, and how often?
• If I have surgery to remove my bladder, would radiation afterward make sense for me?

References

1. "ASTRO Issues Its First Clinical Guideline on Radiation Therapy for Bladder Cancer." American Society for Radiation Oncology. Sept. 17, 2026.
2. "Radiation Therapy for Bladder Cancer: An ASTRO Clinical Practice Guideline." Ballas LK, Efstathiou JA, et al. Practical Radiation Oncology. Sept. 17, 2026.

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