Table 2.
Overview of the Role of RT in MIBC in the Neoadjuvant, Adjuvant and Recurrent Treatment Setting, as Recommend by the Consulted Guidelines
| Guideline* | Evidence/ Recommendation | Level/ Strength |
|---|---|---|
| Neoadjuvant radiotherapy | ||
| EAU | No contemporary data exists to support that pre-operative RT for operable MIBC increases survival.5 | LE: 2A |
| Pre-operative RT for operable MIBC, using a dose of 45–50Gy in fractions of 1.8–2Gy, results in down-staging after 4 to 6 weeks.5 | LE: 2 | |
| Limited high-quality evidence supports the use of pre-operative RT to decrease local recurrence of MIBC after RC.5 | LE: 3 | |
| Do not offer pre-operative RT for operable MIBC since it will only result in down-staging, but will not improve survival.5 | SR: Strong | |
| Do not offer pre-operative RT when subsequent RC with urinary diversion is planned.5 | SR: Strong | |
| NCCN | For invasive tumors, consider low-dose preoperative RT prior to segmental cystectomy.7 | 2B |
| Adjuvant radiotherapy | ||
| EAU | Addition of adjuvant RT to chemotherapy is associated with an improvement in local relapse-free survival following cystectomy for locally-advanced bladder cancer (pT3b–4, or node-positive).5 | LE: 2A |
| Consider offering adjuvant RT in addition to chemotherapy following RC, based on pathologic risk (pT3b–4 or positive nodes or positive margins).5 | SR: Weak | |
| ESMO | Adjuvant RT (with or without radiosensitising chemotherapy) is not standard treatment of patients with MIBC.6 | III, C |
| NCCN | Based on pathologic risk, consider adjuvant RT in selected patients (pT3- 4, positive nodes/margins).7 | LE: 2B |
| Local recurrence/ persistent disease | ||
| EAU | Offer RT, chemotherapy and possibly surgery as options for treatment, either alone or in combination.5 | SR: Strong |
| NCCN | Subsequent-line therapy for metastatic disease or local recurrence includes CRT (if no previous RT), or RT.7 | LE: 2A |
| RT alone can also be considered as a subsequent-line therapy for patients with metastatic disease or local recurrence following cystectomy, especially in selected cases with regional only recurrence or with clinical symptoms.7 | LE: 2A | |
Notes: *Characteristics of the consulted guidelines, including the system used for evidence and recommendation grading, are summarized in Supplementary Table 1. No RT recommendations provided for the neoadjuvant, adjuvant and recurrent MIBC setting by the AUA/ASCO/ASTRO/SUO and NICE guidelines.
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; ESMO, European Society of Medical Oncology; LE, level of evidence; MIBC, muscle-invasive bladder cancer; NCCN, National Comprehensive Cancer Network; NICE, National Institute for Health and Care Excellence; PT, pathologic tumor stage; RC, radical cystectomy; RT, radiotherapy; SR, strength rating; T, tumor.