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Objectives: Immune checkpoint inhibitors (ICIs) are indicated for metastatic urothelial cancer (mUC), but predictive and prognostic factors are lacking. We investigated clinical variables associated with ICI outcomes., Methods: We performed a multicentre retrospective cohort study of 135 patients who received ICI for mUC, 2016-2021, at three Canadian centres. Clinical characteristics, body mass index (BMI), metastatic sites, neutrophil-to-lymphocyte ratio (NLR), response and survival were abstracted from chart review., Results: We identified 135 patients and 62% had received ICI as a second-line or later treatment for mUC. A BMI ≥25 was significantly correlated to a higher overall response rate (ORR) (45.4% vs 16.3%, p value=0.020). Patients with BMI ≥30 experienced longer median overall survival (OS) of 24.8 vs 14.4 for 25≤BMI<30 and 8.5 months for BMI <25 (p value=0.012). The ORR was lower in the presence of bone metastases (16% vs 41%, p value=0.006) and liver metastases (16% vs 39%, p value=0.013). Metastatic lymph nodes were correlated with higher ORR (40% vs 20%, p value=0.032). The median OS for bone metastases was 7.3 versus 18 months (p value <0.001). Patients with liver metastases had a median OS of 8.6 versus 15 months (p value=0.006). No difference for lymph nodes metastases (13.5 vs 12.7 months, p value=0.175) was found. NLR ≥4 had worse OS (8.2 vs 17.7 months, p value=0.0001). In multivariate analysis, BMI ≥30, bone metastases, NLR ≥4, performance status ≥2 and line of ICI ≥2 were independent factors for OS., Conclusions: Our data identified BMI and bone metastases as novel clinical biomarkers that were independently associated with ICI outcomes in mUC. External and prospective validation are warranted., Competing Interests: Competing interests: Nicholas Meti—Honoraria: Takeda, Novartis. Consulting: Takeda, Seagen, AstraZeneca, Pfizer. Srikala S Sridhar—Consulting: Astellas, AstraZeneca, Bayer, Bicycle Therapeutics, BMS, Eisai, EMD Serono, Gilead, Ipsen, Janssen, Merck, Pfizer, Seagen; Research funding (Institution): Janssen, Seagen, EMD Serono. Rossanna C Pezo—Honoraria: Pfizer, Novartis, BMS, Merck, Sanofi, Gilead, AstraZeneca; Research funding (Institution): Merck, Novartis, Pfizer, Taiho, Jazz Pharmaceuticals, ZymeWorks, AstraZeneca. Cristiano Ferrario—Honoraria: Pfizer, Bayer, Novartis, Roche, Bayer, Knight therapeutics, AstraZeneca, Merck, Astellas Pharma; Consulting—Merck, Novartis, AstraZeneca, Roche; Research funding (Institution): Merck, Novartis, Pfizer, Lilly, ZymeWorks, AstraZeneca, Janssen Oncology, Bayer, Astellas Pharma, Roche, Sanofi, Seattle Genetics, Semonix Pharmaceuticals, Bicycle Therapeutics, Immunomedics. Susanna Cheng—Consulting: AstraZeneca, Merck. April A N Rose—Consulting: EMD Serono, Advanced accelerator applications/Novartis; Research funding (Personal): Canadian Institutes of Health Research CIHR, Canadian Cancer Society, Conquer Cancer Foundation, Jewish General Hospital Foundation, TransMedTech Institute, Canada Foundation of Innovation; Research Funding (Institution): AstraZeneca, Merck, Pfizer, Seattle Genetics; Employment: Family member Merck. Soumaya Labidi, Mengqi Li, Sonia V Del Rincon, Reeta Barua, Jamila Riromar, Di Maria Jiang, Nazanin Fallah-Rad, Adrian G Sacher: no competing interests., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Background: In metastatic urothelial cancer (mUC), bone metastasis (BM) are associated with significant morbidity and mortality, yet their role as an independent prognostic variable remains unclear. We aimed to determine the impact of BM on overall survival (OS) in patients with mUC treated with first-line platinum-based chemotherapy (PBC)., Methods: mUC patients receiving PBC at the Princess Margaret Cancer Center, Tom Baker Cancer Center, or Cross Cancer Institute from January 2005 to January 2018 were identified retrospectively using central pharmacy database records. Patient disease, treatment, and response characteristics were collected. Progression-free survival (PFS) and OS were estimated using the Kaplan-Meier method. Variables reaching significance ( p  < 0.05) in univariable analysis (UVA) of survival (OS) were included in multivariable analysis (MVA) (Cox)., Results: Overall, 376 patients with a median follow-up of 16.8 (range: 2.2-218.3) months were included. Median age was 67 (range: 28-91) years, 76% were male, 63% had an Eastern Cooperative Oncology Group performance status (ECOG PS) of 0-1, and 41% had BM. All patients received first-line PBC. Patients with BM had inferior median PFS (4.9 months (95% CI 3.6-6.2) versus 6.5 months (95% CI 5.4-7.6), p  = 0.03) and median OS (8.8 months (95% CI 7.8-9.7) versus 10.8 months (95% CI 9.1-12.5), p  = 0.002). In UVA, ECOG PS 2-3 ( p  < 0.001), presence of BM ( p  = 0.002), and WBC count ⩾ 11,000 cells/mm 3 ( p  = 0.001) were associated with inferior survival. Prior cystectomy ( p  < 0.001) and lack of progression (stable disease, partial or complete response) on treatment was associated with improved OS ( p  < 0.001). These variables maintained significance in MVA., Conclusion: In this retrospective study, mUC patients with BM had worse OS suggesting that BM may be an independent negative prognostic factor and including BM as a stratification factor in future mUC clinical trial designs may be warranted. A greater focus must be placed on novel therapeutic strategies to better manage BM to reduce both morbidity and mortality., Competing Interests: Conflict of interest statement: The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: ZWV has received honoraria from Pfizer, Exact Sciences, Knight Pharmaceuticals, Novartis, Gilead pharmaceuticals, and AstraZeneca. DMJ has received honoraria from Janssen, Ipsen, Bayer, Amgen, EMD Serono, and Pfizer and consulting fees from Bayer. SSS has received consulting fees from Astellas, AstraZeneca, Bayer, Bristol Myers Squibb, Eisai, EMD Serono, Hoffmann-La Roche, Immunomedics, Ipsen, Janssen, Merck, Pfizer, and Seagen; she has also received research funding from Bayer and Janssen pharmaceuticals. The remaining authors declare no conflicts of interest., (© The Author(s), 2022.)