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Although guidelines exist for advanced and variant bladder cancer management, evidence is limited/conflicting in some areas and the optimal approach remains controversial. Background: Although guidelines exist for advanced and variant bladder cancer management, evidence is limited/conflicting in some areas and the optimal approach remains controversial. Objective: To bring together a large multidisciplinary group of experts to develop consensus statements on controversial topics in bladder cancer management. Design: A steering committee compiled proposed statements regarding advanced and variant bladder cancer management which were assessed by 113 experts in a Delphi survey. Statements not reaching consensus were reviewed; those prioritised were revised by a panel of 45 experts before voting during a consensus conference. Setting: Online Delphi survey and consensus conference. Participants: The European Association of Urology (EAU), the European Society for Medical Oncology (ESMO), experts in bladder cancer management. Outcome measurements and statistical analysis: Statements were ranked by experts according to their level of agreement: 1–3 (disagree), 4–6 (equivocal), 7–9 (agree). A priori (level 1) consensus was defined as 70% agreement and 15% disagreement, or vice versa. In the Delphi survey, a second analysis was restricted to stakeholder group(s) considered to have adequate expertise relating to each statement (to achieve level 2 consensus). Results and limitations: Overall, 116 statements were included in the Delphi survey. Of these, 33 (28%) statements achieved level 1 consensus and 49 (42%) statements achieved level 1 or 2 consensus. At the consensus conference, 22 of 27 (81%) statements achieved consensus. These consensus statements provide further guidance across a broad range of topics, including the management of variant histologies, the role/limitations of prognostic biomarkers in clinical decision making, bladder preservation strategies, modern radiotherapy techniques, the management of oligometastatic disease and the evolving role of checkpoint inhibitor therapy in metastatic disease. Conclusions: These consensus statements provide further guidance on controversial topics in advanced and variant bladder cancer management until a time where further evidence is available to guide our approach, The authors would like to thank Peter E. Clark from Atrium Health, Levine Cancer Institute, Charlotte, NC, USA, for his contribution to the Delphi survey. Angela Corstorphine of Kstorfin Medical Communications Ltd provided medical writing support with the preparation of this manuscript; this support was funded jointly by EAU and ESMO.

Background Pre-treatment lymphocytopaenia may result from cytokines secreted by the tumour microenvironment in association with aggressive tumour biology. We sought to establish the prognostic significance of lymphocytopaenia in muscle-invasive and advanced bladder cancer. Patients and methods Seventy-four patients with muscle-invasive bladder cancer treated with radical chemoradiotherapy and 131 patients with advanced bladder cancer treated with palliative chemotherapy were included in the study. The absolute lymphocyte count on the first day of treatment was recorded. Invasive local or systemic recurrence in the muscle-invasive bladder cancer cohort and all-cause mortality in the advanced bladder cancer cohort were defined as survival end points. Receiver operating characteristic (ROC) curve analysis was utilized to determine the cut-off for defining lymphocytopaenia in the muscle-invasive bladder cancer cohort followed by multivariable analysis in a model evaluating the following variables: anaemia, neutrophilia, tumour stage, hydronephrosis and neoadjuvant chemotherapy. Subsequently, lymphocytopaenia was assessed in a multivariable model of the advanced bladder cancer cohort analysing the following prognostic variables: neutrophilia, anaemia, performance status and presence of bone or visceral metastases. A further analysis was carried out evaluating absolute lymphocyte count as a continuous variable. Results An absolute lymphocyte count of 1.5 × 109/l was determined as the cut-off on ROC curve analysis in the muscle-invasive bladder cancer cohort, and multivariate analysis revealed that only lymphocytopaenia was predictive for inferior outcome in this cohort. In the advanced bladder cancer cohort, lymphocytopaenia [hazard ratio (HR) 1.6, 95% confidence interval (CI) 1.1–2.4; P = 0.02] and performance status (HR 1.7, 95% CI 1.0–2.7; P = 0.047) were adverse prognostic factors in the binary variable multivariate model. Absolute lymphocyte count was the sole significant factor when analysed as a continuous variable (HR 0.66, 95% CI 0.5–0.87; P = 0.003). Conclusion Pre-treatment lymphocytopaenia is an independent adverse prognostic factor in both muscle-invasive and advanced bladder cancer. It may be a manifestation of cancer-induced immune suppression driving tumour progression.

Background Radical radiotherapy is the mainstay of bladder preservation treatment for muscle-invasive bladder cancer (MIBC) patients. The concurrent use of radiosensitisers improves patient outcome (Caffo et al., 2016, Hoskin et al., 2010). However, different factors may preclude patients from receiving radiosensitisers. This retrospective study evaluates the survival and toxicity outcomes of bladder preservation treatment in a tertiary cancer centre. Methods Patients treated with radical radiotherapy from 2010 to 2017 were divided into two groups depending on whether they received radiosensitisers in addition to radiotherapy. The primary outcome was overall survival (OS) and the secondary outcome was rate of late toxicities. Kaplan-Meier analyses were used to analyse OS. Late genitourinary (GU) and gastrointestinal (GI) toxicities were defined as treatment-related toxicities at 1-year post-treatment, assessed on the LENT/SOMA scale. Results A total of 428 patients were included in the survival analysis. 303 patients had combination treatment while 125 patients had radiotherapy alone. Patients in the combination group were younger (median age 72 vs 81, p Table . : 219P Rates of late toxicities following radical radiotherapy Combination (N = 303) Radiotherapy (N = 125) GU Toxicity Any grade 119 (39.3%) 2 (1.6%) Grade 3-4 4 (1.3%) 1 (0.8%) GI Toxicity Any grade 133 (43.9%) 2 (1.6%) Grade 3-4 4 (1.3%) 0 (0%) Conclusions The survival outcome with radiosensitisation in this real-world retrospective study is in keeping with published data. Bladder preservation is effective with minimal long-term toxicities. Patients with localised MIBC should be offered the option of bladder preservation treatment. Legal entity responsible for the study Radiotherapy-Related Research Group, The Christie Hospital NHS Foundation Trust. Funding Has not received any funding. Disclosure All authors have declared no conflicts of interest.