While biological phosphorus removal (BPR) has been practised for 30 years, up to recently it has been restricted mainly to activated sludge processes, with the corresponding need for large basin volumes. Yet, research with biofilm reactors showed that the principle of alternate anaerobic and aerated conditions was applicable to fixed bacteria by changing the conditions in time rather than in space. Attached growth enhanced biological phosphorus removal (EBPR) systems are attractive because of their compactness and capability to retain high biomass levels. However, the phosphorus extraction depends on backwashes to enhance the phosphorus-rich attached biomass, and correct control of unsteady effluent quality created by frequently modified process conditions. Accordingly, EBPR remains a challenging task in terms of combining nitrogen and phosphorus removal using attached growth systems. Nevertheless, a combination of activated sludge and biofilm carriers, in the integrated fixed-film activated sludge system, provides treatment opportunities not readily available using suspended growth systems. Current practice is only at the beginning of exploiting the full potential of this combination, but the first full-scale results show that compact tankage and low nutrient results based on biological principles are possible.