Table 1.
Overview of the Role of RT as Primary Treatment for MIBC, as Recommend by the Consulted Guidelines
| Guideline* | Evidence/ Recommendation | Level/ Strength |
|---|---|---|
| Primary radiotherapy | ||
| EAU | Radiochemotherapy/ Multi-modality treatment | |
| In selected patient population, long-term survival rates of TMT are comparable to those of early cystectomy.5 | LE: 2B | |
| Offer surgical intervention or TMT to appropriate candidates as primary curative therapeutic approaches since they are more effective than RT alone.5 | SR: Strong | |
| Offer TMT as an alternative to selected, well informed and compliant patients, especially for whom RC is not an option or not acceptable†.5 | SR: Strong | |
| In patients with clinical T4 or clinical N+ disease (regional), radical CRT can be offered accepting that this may be palliative rather than curative in outcome (EAU-ESMO consensus statement).5 | NA | |
| CRT should be given to improve local control in cases of inoperable locally advanced tumours (EAU-ESMO consensus statements).5 | NA | |
| Radiotherapy-alone | ||
| External beam RT alone should only be considered as therapeutic option when the patient is unfit for cystectomy.5 | LE: 3 | |
| Do not offer RT alone as primary treatment for localised bladder cancer | SR: Strong | |
| EBRT can be an alternative treatment in patients unfit for radical surgery or concurrent chemotherapy.5 | NA | |
| AUA/ ASCO/ ASTRO/ SUO | Radiochemotherapy/ Multi-modality treatment | |
| A multi-modal bladder preserving approach with its merits and disadvantages should be discussed in each individual case. The studies that evaluate curative bladder preserving strategies, as a general rule, have highly select patient populations. The Panel found no strong evidence to determine whether or not immediate cystectomy improved survival when compared to initial bladder sparing protocols that employ salvage cystectomy as therapy for persistent bladder cancer.9 | NA | |
| The Panel believes that multi-modal bladder preserving therapy is the preferred treatment in those patients who desire bladder preservation and understand the unique risks associated with this approach and/or those who are medically unfit for surgery.9 | NA | |
| For patients with newly diagnosed non-metastatic MIBC who desire to retain their bladder, and for those with significant comorbidities for whom RC is not a treatment option, clinicians should offer bladder preserving therapy when clinically appropriate.9 | Clinical Principle | |
| Radiotherapy-alone | ||
| For patients with MIBC, clinicians should not offer RT alone as a curative treatment.9 | LE: C SR: Strong |
|
| ESMO | Organ-preservation therapy with RT, as part of multimodal schema for MIBC, is a reasonable option for patients seeking an alternative to RC† and an option for those who are medically unfit for surgery.6 | II, B |
| NCCN | Radiochemotherapy/ Multi-modality treatment | |
| Bladder-preserving approaches are reasonable alternatives to RC for patients who are medically unfit for surgery and those seeking an alternative to RC.7 | NA | |
| Stage II (T2, N0) and Stage IIIA (T3-T4a, N0; T1-T4a, N1).7 Stage IIB (T1-T4a, N2-3) and IVA (T4b, any N, M0).7 |
LE: 1 LE: 2A |
|
| Radiotherapy-alone | ||
| RT alone is inferior to RT combined with chemotherapy for patients with an invasive bladder tumor, and is not considered standard for patients who can tolerate combined therapy.7 | NA | |
| RT alone is only indicated for those who cannot tolerate a cystectomy or chemotherapy because of medical comorbidities.7 | NA | |
| Stage II (T2, N0) and Stage IIIA (T3-T4a, N0; T1-T4a, N1) (note: CRT preferred).7 | LE: 2A | |
| NICE | Radiochemotherapy/ Multi-modality treatment | |
| Offer a choice of RC or RT with a radiosensitiser to people with urothelial MIBC for whom radical therapy is suitable Ensure that the choice is based on a full discussion between the person and a urologist who performs RC, a clinical oncologist and a clinical nurse specialist.8 | LE: Very low-low | |
Notes: *Characteristics of the consulted guidelines, including the system used for evidence and recommendation grading, are summarized in Supplementary Table 1. †Underlined text indicates modifications to the guidelines (since our previous review in 2017) which encourage a treatment choice based on patient preference.
Abbreviations: AUA/ASCO/ASTRO/SUO, American Urological Association/American Society of Clinical Oncology/American Society of Radiation Oncology/Society of Urologic Oncology; CRT, chemoradiotherapy; EAU, European Association of Urology; EBRT, external beam radiotherapy; ESMO, European Society of Medical Oncology; LE, level of evidence; M, metastasis; MIBC, muscle-invasive bladder cancer; N, nodes; NA, not available; NCCN, National Comprehensive Cancer Network; NICE, National Institute for Health and Care Excellence; RC, radical cystectomy; RT, radiotherapy; SR, strength rating; T, tumor; TMT, trimodality therapy.