A Delphi consensus for implementing genomic testing in unresectable or metastatic urothelial cancer

OBJECTIVES: To establish a UK consensus vision of a standardised genomic testing pathway in unresectable/metastatic urothelial cancer (mUC) with clear roles and responsibilities for multidisciplinary team (MDT) members and molecular pathology laboratory teams, and to agree how the pathway must evolve to accommodate emerging innovations. SUBJECTS AND METHODS: A modified Delphi method was used. Six healthcare professionals (HCPs) with expertise in UC formed the Steering Committee (SC), which met in May 2025. Seven key consensus topics were developed covering the steps of the pre-testing and genomic testing pathways, the current and future state of precision medicine, and approaches to overcome barriers and ensure readiness for the future. Within these topics, statements were developed and distributed to clinical scientists and HCPs via an on-line 4-point Likert scale survey. Respondents could opt out of responding to statements outside their area of expertise. Consensus was pre-defined as ≥75% agreement. RESULTS: Overall, 50 responses were received; consensus was reached on 41/42 statements. The statement that did not achieve consensus was part of a paired set. A proposed pathway for pre-testing and genomic testing in unresectable or mUC was developed based on survey results and discussions at SC meetings. Key priorities for the pathway include: timely fibroblast growth factor receptor 3 testing, ideally at the commencement of first-line systemic therapies; selection of specimens based on volume of tissue and recency; immediate access to the genomic testing report for all MDT members; and secure data environments with federated access to genomic results. Since the stopping criteria were met, no further survey rounds were required. CONCLUSION: Adopting the genomic testing pathway derived from this Delphi consensus will provide greater clarity around MDT and molecular laboratory responsibilities, reduce regional inequities in access, and optimise patient outcomes through timely delivery of genomic testing and subsequent treatment.