Background: Guidelines advocate for including a Comprehensive Geriatric Assessment (CGA) in the evaluation of elderly bladder cancer (BC) patients. To date, CGAs have not been studied in clinical pHypotheses: Integrating a comprehensive Risk and Resilience (R2) assessment in shared decision-making for localized BC will decrease decisional conflict and anxiety/depression, while improving generic health-related quality of life (HRQOL) and satisfaction with cancer-care satisfaction at treatment selection. Additionally, the R2 assessment will alter physicians’ subjective risk assessment and decrease physician-reported decisional-conflict score (DCS). Aims: 1)To compare changes in patient-reported decisional conflict and health-related quality of life among localized BC patients who completed the R2 assessment with those undergoing the usual risk assessment.2)To test the impact of the R2 assessment on provider’s subjective assessment of a patient’s fitness for definitive treatment for BC and physician-reported DCS after treatment selection. Methodologies: We will perform a prospective observational cohort study. Following informed consent, patients will receive standard of care risk assessment for 3 months and will serve as controls. Following treatment selection, patients will complete the DCS, PHQ-4 (anxiety and depression), QLQ-C30 and QLQ-BLM30 (HRQOL), and satisfaction with cancer care assessments; physicians will complete the DCS and render a subjective assessment of patients’ fitness for treatment. Patients being seen in months 4-11 will receive the R2 assessment. Patients and physicians will complete the outcome surveys as per above. Patient and physician-reported outcome measures will be compared between usual care and intervention cohorts. Concordance between physician risk assessment with/without the R2 score will be measured. This project responds to the BCAN PSN knowledge gaps in decision-making before definitive treatment of muscle-invasive BC.