Patient Activation as a Pathway to Shared Decision-making for Adults with Diabetes or Cardiovascular Disease.

BACKGROUND: Shared decision-making (SDM) is widely recognized as a core strategy to improve patient-centered care. However, the implementation of SDM in routine care settings has been slow and its impact mixed. OBJECTIVE: We examine the temporal association of patient activation and patients' experience with the SDM process to assess the dominant directionality of this relationship. DESIGN: Patient activation, or a patients' knowledge, skills, and confidence in self-management, was assessed using the 13-item Patient Activation Measure (PAM). Patient-reported assessment of the SDM process was assessed using the 3-item CollaboRATE measure. Patients at 16 adult primary care practices were surveyed in 2015 and 2016 on PAM (α = 0.92), CollaboRATE (α = 0.90), and demographics. The relationship between PAM and CollaboRATE was estimated using a cross-lagged panel model with clustered robust standard errors and practice fixed effects, controlling for patient characteristics. PARTICIPANTS: 1222 adult patients with diabetes and/or cardiovascular disease with survey responses at baseline (51% response rate) and a 1-year follow-up (73% response rate). RESULTS: PAM (mean 3.27 vs 3.28 on a range of 1 to 4; p = 0.082) and CollaboRATE (mean 3.62 vs 3.63 on a range of 1 to 5; p = 0.14) did not change significantly over time. In adjusted analyses, the path from baseline PAM to follow-up CollaboRATE (ß = 0.35; p < 0.0001) was stronger than the path from baseline CollaboRATE to follow-up PAM (ß = 0.04; p = 0.001). CONCLUSIONS: The relationship between patient activation and patients' experiences of the SDM process is bidirectional, but dominated by baseline patient activation. Rather than promoting the use of SDM for all patients, healthcare organizations should prioritize interventions to promote patient activation and engage patients with relatively high activation in SDM interventions.

Linking Practice Adoption of Patient Engagement Strategies and Relational Coordination to Patient-Reported Outcomes in Accountable Care Organizations.

Policy Points Accountable care organizations (ACOs) have incentives to promote the adoption of patient engagement strategies such as shared decision making and self-management support programs to improve patient outcomes and contain health care costs. High adoption of patient engagement strategies among ACO-affiliated practices did not improve patient-reported outcomes (PROs) of physical, emotional, and social function among adult patients with diabetes and/or cardiovascular disease over a one-year time frame, likely because implementing these strategies requires extensive clinician and staff training, workflow redesign, and patient participation over time. A dominant focus on improving clinical measures to meet external requirements may crowd out time needed for care team members to address other outcomes that matter to patients, including PROs. Payers and policy-makers should explicitly incentivize the collection and use of PROs when contracting with ACOs. CONTEXT: Adult primary care practices of accountable care organizations (ACOs) are adopting a range of patient engagement strategies, but little is known about how these strategies are related to patient-reported outcomes (PROs) and how relational coordination among team members aids implementation. METHODS: We used a mixed-methods cohort study design integrating administrative and clinical data with two data collection waves (2014-2015 and 2016-2017) of clinician and staff surveys (n = 764), surveys of adult patients with diabetes and/or cardiovascular disease (CVD) (n = 1,276), and key informant interviews of clinicians, staff, and administrators (n = 103). Multivariable linear regression estimated the relationship of practice adoption of patient engagement strategies, relational coordination, and PROs of physical, social, and emotional function. The mediating role of patient activation was examined using cross-lagged panel models. Key informant interviews assessed how relational coordination influences the implementation of patient engagement strategies. FINDINGS: There were no differential improvements in PROs among patients of practices with high vs. low adoption of patient engagement strategies or among patients of practices with high vs. low relational coordination. The Patient Activation Measure (PAM) is strongly related to better physical, emotional, and social PROs over time. Relational coordination facilitated the implementation of patient engagement strategies, but key informants indicated that resources and systems to systematically track treatment preferences and goals beyond clinical indicators were needed to support effective implementation. CONCLUSIONS: Adult patients with diabetes and/or CVD of ACO-affiliated practices with high adoption of patient engagement strategies do not have improved PROs of physical, emotional, and social function over a one-year time frame. Implementing patient engagement strategies increases task interdependence among primary care team members, which needs to be carefully managed. ACOs may need to make greater investment in collecting, monitoring, and analyzing PRO data to ensure that practice adoption and implementation of patient engagement strategies leads to improved physical, emotional, and social function among patients.

Comparison of Postradical Cystectomy Ileus Rates Using GIA-80 Versus GIA-60 Intestinal Stapler Device.

OBJECTIVE: To assess the impact on recovery of bowel function using an 80 mm versus 60 mm gastrointestinal anastomosis (GIA) stapler following radical cystectomy and urinary diversion (RC/UD) for bladder cancer. METHODS: We identified 696 patients using a prospectively maintained RC/UD database from January 2006 to November 2010. Two nonrandomized consecutive cohorts were compared. Patients between January 2006- and December 2007 (n = 180) were treated using a 60 mm GIA stapler, and 331 patients between January 2008 and December 2010 were subject to an 80 mm GIA stapler. All patients were treated on the same standardized postoperative recovery pathway. After accounting for baseline patient and perioperative characteristics, using a multivariable logistic regression model, we directly compared rates of postoperative ileus using a standardized definition. RESULTS: Of 511 evaluable patients, ileus was observed in 32% (57/180) for 60 mm GIA versus 33% (110/331) for the 80 mm GIA. Preoperative renal function, age, gender, body mass index, and type of diversion were comparable between cohorts. On multivariate analysis, stapler size was not significantly associated with the development of ileus (GIA-60 vs GIA-80: OR 1.11; 95% CI 0.75, 1.66; P = .6). Positive fluid balance was associated with an increased risk (P = .019) and female sex a decreased risk (P = .008) of developing ileus compared to patients with negative fluid balance. CONCLUSION: The size of the intestinal bowel anastomosis (GIA 80 mm vs 60 mm) does not independently impact the time to bowel recovery following RC/UD.

Twenty-year Risk of Prostate Cancer Death by Midlife Prostate-specific Antigen and a Panel of Four Kallikrein Markers in a Large Population-based Cohort of Healthy Men.

BACKGROUND: Prostate-specific antigen (PSA) screening reduces prostate cancer deaths but leads to harm from overdiagnosis and overtreatment. OBJECTIVE: To determine the long-term risk of prostate cancer mortality using kallikrein blood markers measured at baseline in a large population of healthy men to identify men with low risk for prostate cancer death. DESIGN, SETTING, PARTICIPANTS: Study based on the Malmö Diet and Cancer cohort enrolling 11 506 unscreened men aged 45-73 yr during 1991-1996, providing cryopreserved blood at enrollment and followed without PSA screening to December 31, 2014. We measured four kallikrein markers in the blood of 1223 prostate cancer cases and 3028 controls. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Prostate cancer death (n=317) by PSA and a prespecified statistical model based on the levels of four kallikrein markers. RESULTS AND LIMITATIONS: Baseline PSA predicted prostate cancer death with a concordance index of 0.86. In men with elevated PSA (≥2.0ng/ml), predictive accuracy was enhanced by the four-kallikrein panel compared with PSA (0.80 vs 0.73; improvement 0.07; 95% confidence interval 0.04, 0.10). Nearly half of men aged 60+ yr with elevated PSA had a four-kallikrein panel score of <7.5%, translating into 1.7% risk of prostate cancer death at 15 yr-a similar estimate to that of a man with a PSA of 1.6ng/ml. Men with a four-kallikrein panel score of ≥7.5% had a 13% risk of prostate cancer death at 15 yr. CONCLUSIONS: A prespecified statistical model based on four kallikrein markers (commercially available as the 4Kscore) reclassified many men with modestly elevated PSA, to have a low long-term risk of prostate cancer death. Men with elevated PSA but low scores from the four-kallikrein panel can be monitored rather than being subject to biopsy. PATIENT SUMMARY: Men with elevated prostate-specific antigen (PSA) are often referred for prostate biopsy. However, men with elevated PSA but low scores from the four-kallikrein panel can be monitored rather than being subject to biopsy.

Physician Practice Transitions to System Ownership Do Not Result in Diminished Practice Responsiveness to Patients.

OBJECTIVE: To examine the extent to which physician-to-system ownership transitions are associated with declines in practice-reported patient responsiveness (PRPR). DATA SOURCES: A longitudinal cohort of practices (n = 897) from the National Survey of Large Physician Organizations/National Survey of Small- and Medium-Sized Physician Organizations (2006/08) and the National Survey of All-Size Physician Organizations (2012/13). STUDY DESIGN: Multivariable regression estimated the effect of ownership on changes in PRPR, controlling for practice size, specialty composition, other practice, and market characteristics. DATA COLLECTION/EXTRACTION METHODS: Data were collected from three nationally representative surveys of physician organizations consisting of 40-minute interviews with the medical director, president, or chief executive officer. PRINCIPAL FINDINGS: Nine percent of organizations transitioned to system ownership. Compared to practices that were continuously physician-owned, practices that switched to system ownership did not have significantly lower PRPR at baseline but continuously system-owned practices did. Transitions to system ownership were associated with increased PRPR compared to continuously physician ownership. Increased practice size and changes in specialty composition, however, were associated with diminished PRPR. CONCLUSIONS: Practices can maintain or improve strategies to address patient concerns when transferring ownership to systems with careful attention to the impact of increased size and changes in specialty composition.

A Multilevel Analysis of Patient Engagement and Patient-Reported Outcomes in Primary Care Practices of Accountable Care Organizations.

BACKGROUND: The growing movement toward more accountable care delivery and the increasing number of people with chronic illnesses underscores the need for primary care practices to engage patients in their own care. OBJECTIVE: For adult primary care practices seeing patients with diabetes and/or cardiovascular disease, we examined the relationship between selected practice characteristics, patient engagement, and patient-reported outcomes of care. DESIGN: Cross-sectional multilevel observational study of 16 randomly selected practices in two large accountable care organizations (ACOs). PARTICIPANTS: Patients with diabetes and/or cardiovascular disease (CVD) who met study eligibility criteria (n = 4368) and received care in 2014 were randomly selected to complete a patient activation and PRO survey (51% response rate; n = 2176). Primary care team members of the 16 practices completed surveys that assessed practice culture, relational coordination, and teamwork (86% response rate; n = 411). MAIN MEASURES: Patient-reported outcomes included depression (PHQ-4), physical functioning (PROMIS SF12a), and social functioning (PROMIS SF8a), the Patient Assessment of Chronic Illness Care instrument (PACIC-11), and the Patient Activation Measure instrument (PAM-13). Patient-level covariates included patient age, gender, education, insurance coverage, limited English language proficiency, blood pressure, HbA1c, LDL-cholesterol, and disease comorbidity burden. For each of the 16 practices, patient-centered culture and the degree of relational coordination among team members were measured using a clinician and staff survey. The implementation of shared decision-making activities in each practice was assessed using an operational leader survey. KEY RESULTS: Having a patient-centered culture was positively associated with fewer depression symptoms (odds ratio [OR] = 1.51; confidence interval [CI] 1.04, 2.19) and better physical function scores (OR = 1.85; CI 1.25, 2.73). Patient activation was positively associated with fewer depression symptoms (OR = 2.26; CI 1.79, 2.86), better physical health (OR = 2.56; CI 2.00, 3.27), and better social health functioning (OR = 4.12; CI 3.21, 5.29). Patient activation (PAM-13) mediated the positive association between patients' experience of chronic illness care and each of the three patient-reported outcome measures-fewer depression symptoms, better physical health, and better social health. Relational coordination and shared decision-making activities reported by practices were not significantly associated with higher patient-reported outcome scores. CONCLUSIONS: Diabetic and CVD patients who received care from ACO-affiliated practices with more developed patient-centered cultures reported lower PHQ-4 depression symptom scores and better physical functioning. Diabetic and CVD patients who were more highly activated to participate in their care reported lower PHQ-4 scores and better physical and social outcomes of care.

Longitudinal assessment of quality of life after surgery, conformal brachytherapy, and intensity-modulated radiation therapy for prostate cancer.

PURPOSE: We evaluated quality-of-life changes (QoL) in 907 patients treated with either radical prostatectomy (open or laparoscopic), real-time planned conformal brachytherapy, or high-dose intensity-modulated radiotherapy (IMRT) on a prospective IRB-approved longitudinal study. METHODS: Validated questionnaires given pretreatment (baseline) and at 3, 6, 9, 12, 15, 18, 24, 36, and 48 months addressed urinary function, urinary bother, bowel function, bowel bother, sexual function, and sexual bother. RESULTS: At 48 months, surgery had significantly higher urinary incontinence than others (both P<.001), but fewer urinary irritation/obstruction symptoms (all P<.001). Very low levels of bowel dysfunction were observed and only small subsets in each group showed rectal bleeding. Brachytherapy and IMRT showed better sexual function than surgery accounting for baseline function and other factors (delta 14.29 of 100, 95% CI, 8.57-20.01; and delta 10.5, 95% CI, 3.78-17.88). Sexual bother was similar. Four-year outcomes showed persistent urinary incontinence for surgery with more obstructive urinary symptoms for radiotherapy. Using modern radiotherapy delivery, bowel function deterioration is less-often observed. Sexual function was strongly affected in all groups yet significantly less for radiotherapy. CONCLUSIONS: Treatment selection should include patient preferences and balance predicted disease-free survival over a projected time vs potential impairment of QoL important for the patient.

An Arterial Based Complexity (ABC) Scoring System to Assess the Morbidity Profile of Partial Nephrectomy.

BACKGROUND: Tumor characteristics affect surgical complexity and outcomes of partial nephrectomy (PN). OBJECTIVE: To develop an Arterial Based Complexity (ABC) scoring system to predict morbidity of PN. DESIGN, SETTING, AND PARTICIPANTS: Four readers independently scored contrast-enhanced computed tomography images of 179 patients who underwent PN. INTERVENTION: Renal cortical masses were categorized by the order of vessels needed to be transected/dissected during PN. Scores of 1, 2, 3S, or 3H were assigned to tumors requiring transection of interlobular and arcuate arteries, interlobar arteries, segmental arteries, or in close proximity of the renal hilum, respectively during PN. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Interobserver variability was assessed with kappa values and percentage of exact matches between each pairwise combination of readers. Linear regression was used to evaluate the association between reference scores and ischemia time, estimated blood loss, and estimated glomerular filtration rates at 6 wk and 6 mo after surgery adjusted for baseline estimated glomerular filtration rate. Fisher's exact test was used to test for differences in risk of urinary fistula formation by reference category assignment. RESULTS AND LIMITATIONS: Pairwise comparisons of readers' score assignments were significantly correlated (all p<0.0001); average kappa = 0.545 across all reader pairs. The average proportion of exact matches was 69%. Linear regression between the complexity score system and surgical outcomes showed significant associations between reference category assignments and ischemia time (p<0.0001) and estimated blood loss (p=0.049). Fisher's exact test showed a significant difference in risk of urinary fistula formation with higher reference category assignments (p=0.028). Limitations include use of a single institutional cohort to evaluate our system. CONCLUSIONS: The ABC scoring system for PN is intuitive, easy to use, and demonstrated good correlation with perioperative morbidity. PATIENT SUMMARY: The ABC scoring system is a novel anatomy-reproducible tool developed to help patients and doctors understand the complexity of renal masses and predict the outcomes of kidney surgery.

Variation in serum prostate-specific antigen levels in men with prostate cancer managed with active surveillance.

OBJECTIVE: To describe fluctuations in prostate-specific antigen (PSA) levels in men managed with active surveillance (AS) to determine if a single PSA increase is a consistent measure to use to trigger intervention. PATIENTS AND METHODS: We evaluated data on 541 patients undergoing AS between 1995 and 2011. PSA variation was described by studying the Kaplan-Meier probability of patients' PSA levels reaching 4 or 7 ng/mL, falling below those thresholds, and then rising to those thresholds again. We also examined PSA variation by calculating the Kaplan-Meier probability of a PSA change followed by an equal or greater change in the opposite direction. RESULTS: We analysed data on 541 patients undergoing AS with a median (interquartile range [IQR]) of 8 (6-12) PSA measurements and undergoing AS for a median (IQR) of 4 (2-6) years. The 5-year estimate of the probability of reaching a threshold PSA of 7 ng/mL was 40% (95% confidence interval [CI] 35-46%) and the 5-year estimate of subsequently falling below this threshold was 90% (95% CI 82-95%). The 5-year estimate of a PSA direction change was 95% (95% CI 93-97%) overall and 56% (95% CI 51-61%) for PSA direction changes of ≥1 ng/mL. CONCLUSIONS: We observed a high probability of variability in PSA levels for patients on AS. The probability of changes in PSA, defined by an increase to the specified thresholds or a rise >1 ng/mL within 6 months and subsequent decrease of equal or greater value on a subsequent measurement, increases over time; therefore, a single change in PSA level is not a reliable endpoint for patients on AS.

Can Confirmatory Biopsy be Omitted in Patients with Prostate Cancer Favorable Diagnostic Features on Active Surveillance?

PURPOSE: We evaluated whether initial diagnostic parameters could predict the confirmatory biopsy result in patients initiating active surveillance for prostate cancer, to determine whether some men at low risk for disease reclassification could be spared unnecessary biopsy. MATERIALS AND METHODS: The cohort included 392 men with Gleason 6 prostate cancer on initial biopsy undergoing confirmatory biopsy. We used univariate and multivariable logistic regression to assess if high grade cancer (Gleason 7 or greater) on confirmatory biopsy could be predicted from initial diagnostic parameters (prostate specific antigen density, magnetic resonance imaging result, percent positive cores, percent cancer in positive cores and total tumor length). RESULTS: Median patient age was 62 years (IQR 56-66) and 47% of patients had a dominant or focal lesion on magnetic resonance imaging. Of the 392 patients 44 (11%) had high grade cancer on confirmatory biopsy, of whom 39 had Gleason 3+4, 1 had 4+3, 3 had Gleason 8 and 1 had Gleason 9 disease. All predictors were significantly associated with high grade cancer at confirmatory biopsy on univariate analysis. However, in the multivariable model only prostate specific antigen density and total tumor length were significantly associated (AUC 0.85). Using this model to select patients for confirmatory biopsy would generally provide a higher net benefit than performing confirmatory biopsy in all patients, across a wide range of threshold probabilities. CONCLUSIONS: If externally validated, a model based on initial diagnostic criteria could be used to avoid confirmatory biopsy in many patients initiating active surveillance.

Interobserver variability of R.E.N.A.L., PADUA, and centrality index nephrometry score systems.

PURPOSE: To assess interobserver variability of R.E.N.A.L., preoperative aspects and dimensions used for an anatomical classification system (PADUA), and centrality index (C-Index) systems among observers with varying degrees of clinical experience and each system's subscale correlation with surgical outcome metrics. METHODS: Computed tomography images of 90 patients who underwent open, laparoscopic, or robot-assisted laparoscopic partial nephrectomy were scored by one radiology fellow, two urology fellows, one radiology resident, and one secondary school student. Agreement among readers was determined calculating intraclass correlation coefficients. Associations between radiology fellow scores (reference standard as reader with greatest clinical experience), ischemia time, and percent change in postoperative estimated glomerular filtration rate (eGFR) were evaluated using Spearman's correlation. RESULTS: Agreement using C-Index method (ICC = 0.773) was higher than with PADUA (ICC = 0.677) or R.E.N.A.L (ICC = 0.660). Agreement between reference and secondary school student was lower than with other physicians, although the differences were not statistically significant. The reference's scores were significantly (p < 0.05) associated with ischemia time on all three scoring systems and with percent change in eGFR at 6 weeks using C-Index (p = 0.016). Tumor size, nearness to sinus, and location relative to polar lines (R.E.N.A.L.) and tumor size, renal sinus involvement, and collecting system involvement (PADUA) correlated with ischemia time (all p ≤ 0.001). No R.E.N.A.L. or PADUA subscales significantly correlated with percent change in postoperative eGFR. CONCLUSIONS: Clinical experience reduces interobserver variability of existing nephrometry systems though not significantly and less so when using directly measureable anatomic variables. Consistently, only measures of tumor size and distance to intrarenal structures were useful in predicting clinically relevant outcomes.

Clinical role of pathological downgrading after radical prostatectomy in patients with biopsy confirmed Gleason score 3 + 4 prostate cancer.

OBJECTIVE: To identify preoperative factors predicting Gleason score downgrading after radical prostatectomy (RP) in patients with biopsy Gleason score 3+4 prostate cancer and to determine if prediction of downgrading can identify potential candidates for active surveillance (AS). PATIENTS AND METHODS: We identified 1317 patients with biopsy Gleason score 3+4 prostate cancers who underwent RP at the Memorial Sloan-Kettering Cancer Center between 2005 and 2013. Several preoperative and biopsy characteristics were evaluated by forward selection regression, and selected predictors of downgrading were analysed by multivariable logistic regression. Decision curve analysis was used to evaluate the clinical utility of the multivariate model. RESULTS: Gleason score was downgraded after RP in 115 patients (9%). We developed a multivariable model using age, prostate-specific antigen density, percentage of positive cores with Gleason pattern 4 cancer out of all cores taken, and maximum percentage of cancer involvement within a positive core with Gleason pattern 4 cancer. The area under the curve for this model was 0.75 after 10-fold cross validation. However, decision curve analysis revealed that the model was not clinically helpful in identifying patients who will downgrade at RP for the purpose of reassigning them to AS. CONCLUSION: While patients with pathological Gleason score 3 + 3 with tertiary Gleason pattern ≤4 at RP in patients with biopsy Gleason score 3 + 4 prostate cancer may be potential candidates for AS, decision curve analysis showed limited utility of our model to identify such men. Future study is needed to identify new predictors to help identify potential candidates for AS among patients with biopsy confirmed Gleason score 3 + 4 prostate cancer.

Prostate size and adverse pathologic features in men undergoing radical prostatectomy.

OBJECTIVE: To investigate the relationship between prostate volume measured from preoperative imaging and adverse pathologic features at the time of radical prostatectomy and evaluate the potential effect of clinical stage on such relationship. METHODS: In 1756 men who underwent preoperative magnetic resonance imaging and radical prostatectomy from 2000 to 2010, we examined associations of magnetic resonance imaging-measured prostate volume with pathologic outcomes using univariate logistic regression and with postoperative biochemical recurrence using Cox proportional hazards models. We also analyzed the effects of clinical stage on the relationship between prostate volume and adverse pathologic features via interaction analyses. RESULTS: In univariate analyses, smaller prostate volume was significantly associated with high pathologic Gleason score (P<.0001), extracapsular extension (P<.0001), and positive surgical margins (P=.032). No significant interaction between clinical stage and prostate volume was observed in predicting adverse pathologic features (all P>.05). The association between prostate volume and recurrence was significant in a multivariable analysis adjusting for postoperative variables (P=.031) but missed statistical significance in the preoperative model (P=.053). Addition of prostate volume did not change C-Indices (0.78 and 0.83) of either model. CONCLUSION: Although prostate size did not enhance the prediction of recurrence, it is associated with aggressiveness of prostate cancer. There is no evidence that this association differs depending on clinical stage. Prospective studies are warranted assessing the effect of initial method of detection on the relationship between volume and outcome.

Relative value of race, family history and prostate specific antigen as indications for early initiation of prostate cancer screening.

PURPOSE: Many guidelines suggest earlier screening for prostate cancer in men at high risk, with risk defined in terms of race and family history. Recent evidence suggests that baseline prostate specific antigen is strongly predictive of the long-term risk of aggressive prostate cancer. We compared the usefulness of risk stratifying early screening by race, family history and prostate specific antigen at age 45 years. MATERIALS AND METHODS: Using estimates from the literature we calculated the proportion of men targeted for early screening using family history, black race or prostate specific antigen as the criterion for high risk. We calculated the proportion of prostate cancer deaths that would occur in those men by age 75 years. RESULTS: Screening based on family history involved 10% of men, accounting for 14% of prostate cancer deaths. Using black race as a risk criterion involved 13% of men, accounting for 28% of deaths. In contrast, 44% of prostate cancer deaths occurred in the 10% of men with the highest prostate specific antigen at age 45 years. In no sensitivity analysis for race and family history did the ratio of risk group size to number of prostate cancer deaths in that risk group approach that of prostate specific antigen. CONCLUSIONS: Basing decisions for early screening on prostate specific antigen at age 45 years provided the best ratio between men screened and potential cancer deaths avoided. Given the lack of evidence that race or family history affects the relationship between prostate specific antigen and risk, prostate specific antigen based risk stratification would likely include any black men or men with a family history who are destined to experience aggressive disease. Differential screening based on risk should be informed by baseline prostate specific antigen.

Clinical outcome of patients with T1 micropapillary urothelial carcinoma of the bladder.

PURPOSE: We report cancer specific outcomes of micropapillary nonmuscle invasive bladder cancer. MATERIALS AND METHODS: We retrospectively reviewed the records of 36 cases restaged within 3 months of the initial diagnosis of micropapillary nonmuscle invasive bladder cancer. Early radical cystectomy within a 3-month landmark after restaging transurethral bladder tumor resection or conservative treatment with intravesical bacillus Calmette-Guérin, surveillance or deferred radical cystectomy was offered according to surgeon and patient preference. The cumulative incidence of cancer specific mortality and metastasis was estimated using the Kaplan-Meier method. Differences in the cumulative incidence of cancer specific mortality and metastasis between the groups were tested using the log rank test. RESULTS: Median patient age was 68 years (IQR 63-77). The male-to-female ratio was 3:1. At restaging all patients had cT1 disease or less. Early radical cystectomy was performed in 15 patients (42%) while 21 (58%) underwent conservative treatment. Median followup after landmark in cancer specific survivors was 3.1 years (IQR 1.1-5.9). The 5-year cumulative incidence of cancer specific mortality was 17% in the early radical cystectomy group and 25% in the conservative management group for an absolute difference of 7% (95% CI -26-41, p = 0.8). The 5-year cumulative incidence of metastasis was 21% and 34%, respectively, with an absolute difference of 13% (95% CI -23-49, p = 0.9). The extent of the micropapillary component was not significantly associated with cancer specific mortality (p = 0.4) or metastasis (p = 0.9). CONCLUSIONS: Using proper selection criteria, including patient and pathological factors, certain patients in whom cT1 micropapillary urothelial carcinoma was managed conservatively did not have significantly worse outcomes than patients treated with early radical cystectomy.