Colorectal Cancer Survivorship Care in the Veterans Affairs Healthcare System

描述(由申请人提供)： 结直肠癌(CRC)在退伍军人和非退伍军人中都是一种常见的、病态的、往往是致命的疾病。早期发现和更好的治疗方案增加了结直肠癌患者的存活率，扩大了对持续生存护理的需求。在结直肠癌幸存者中，两个主要的死亡原因是继发性恶性肿瘤和合并症。为了缓解这些问题，结直肠癌幸存者必须坚持以符合指南的时间间隔进行监视结肠镜检查，以早期发现癌症复发、药物治疗和生活方式建议。在退伍军人事务部(VA)的医疗系统中，只有不到一半的CRC幸存者在手术后7-18个月内接受了符合指南的监视结肠镜检查。VA内部和外部都有证据表明，CRC患者经历了痛苦、对癌症复发的恐惧和抑郁，这阻碍了他们寻求适当的生存护理的能力。人们对CRC幸存者的自我管理做法知之甚少。需要更好地了解国家VA CRC幸存者队列、他们的医疗保健利用模式、感知的健康需求和优先事项，以便采取干预措施，促进适当的癌症幸存者护理。作为长期以退伍军人为中心的研究承诺的第一步，我提出了三个项目：项目1：利用国家退伍军人管理局二级数据库，如退伍军人中央癌症登记中心、药房福利经理等，我将构建和表征退伍军人结直肠癌幸存者的全国队列及其自我管理行为，并定义一个非癌症对照组。确定退伍军人结直肠癌幸存者的当前人口是为这一人群设计自我管理干预的关键基础。该项目涉及：1)在退伍军人事务部接受护理的幸存者的构成，2)他们在哪里接受护理，3)协调生存护理的提供者的类型，4)什么共同情况影响CRC幸存者，5)体重指数和吸烟状况，6)CRC幸存者坚持服用处方药物的医疗拥有率，7)CRC幸存者与非癌症对照组之间这些因素的比较。项目2：我将评估VA CRC幸存者对生存护理自我管理的看法，包括坚持监测结肠镜检查、坚持用药和医疗保健利用。这将需要一种混合的方法，包括对VISN 6中的儿童权利委员会幸存者进行电话定量调查，并对一部分参与者进行定性访谈。评估结直肠癌幸存者对自我管理的认知是设计干预措施的关键组成部分，这些干预措施激励患者采取行动进行慢性病管理和癌症监测。这些患者报告的信息将评估人们认为的：1)癌症复发的易感性和严重性，2)常见慢性病和心血管危险因素(如高血压、高脂血症和糖尿病)的易感性和严重性，以及3)坚持生存自我管理干预的障碍和好处。项目3：利用前两个项目的信息，我将设计并试行自我管理干预措施，以激励退伍军人结直肠癌幸存者坚持生存护理计划。我将对20名接受自我管理干预的结直肠癌幸存者进行试点测试，目的是增加对以下内容的遵守：1)针对心血管疾病相关风险因素的处方药；2)用于结直肠癌监测的监视结肠镜检查。干预材料还将涉及饮食和锻炼模式等生活方式选择。这项先导性试验将阐明对结直肠癌幸存者进行干预是否可行，以及是否可以获得短期用药依从性和接受结肠镜检查的意向。针对这一独特患者群体的自我管理干预将提高生存护理质量。

DESCRIPTION (provided by applicant): Colorectal cancer (CRC) is a common, morbid, and often deadly disease in veterans and non- veterans alike. Early detection and better treatment options have increased survival among CRC patients, expanding the need for continuing survivorship care. Among CRC survivors the two leading causes of death are secondary malignancies and comorbid conditions. To mitigate these problems, CRC survivors must adhere to surveillance colonoscopy at guideline-concordant time intervals for early detection of cancer recurrence, medications, and lifestyle recommendations. In the Veterans Affairs (VA) healthcare system, fewer than half of CRC survivors receive a guideline-concordant surveillance colonoscopy within 7-18 months following surgery. There is evidence both within VA and externally suggesting that CRC patients experience distress, fear over cancer recurrence, and depression that encumbers their ability to seek appropriate survivorship care. Little is known about CRC survivors' self- management practices. A better understanding is needed of the national VA CRC survivor cohort, their healthcare utilization patterns, perceived health needs and priorities in order to intervene to facilitate appropriate cancer survivorship care. As an initial step in a long-term veteran-centric research commitment, I propose three projects: Project 1: Utilizing national VA secondary databases, such as the VA Central Cancer Registry, Pharmacy Benefits Manager, and others, I will construct and characterize a national cohort of VA CRC survivors and their self-management behaviors, and define a non-cancer comparison group. Defining the current population of VA CRC survivors is a critical foundation for designing a self-management intervention for this populace. This project addresses: 1) the composition of survivors receiving care in the VA, 2) where are they receiving care, 3) the types of providers coordinating survivorship care, 4) what comorbid conditions affect CRC survivors, 5) body mass index and smoking status, 6) the medical possession ratio of CRC survivors' adherence to prescribed medications; and 7) how these factors compare between CRC survivors and a non-cancer comparison group. Project 2: I will assess VA CRC survivors' perceptions of self-management for survivorship care, including adherence to surveillance colonoscopy, medication adherence, and healthcare utilization. This will require a mixed methods approach encompassing telephone-based quantitative surveys among CRC survivors in VISN 6 and qualitative interviews for a subset of participants. Assessing CRC survivors' perception of self-management is a critical component in designing interventions that motivate patients to action for chronic disease management and cancer surveillance. This patient-reported information will assess perceived: 1) susceptibility and severity of cancer recurrence, 2) susceptibility and severity of common chronic diseases and CVD risk factors such as hypertension, hyperlipidemia, and diabetes, and 3) barriers and benefits of adhering to a survivorship self-management intervention. Project 3: Equipped with information from the first two projects, I will design and pilot-test a self- management intervention to motivate VA CRC survivors' adherence to a survivorship care plan. I will conduct a pilot test with 20 CRC survivors of a self-management intervention targeting increased adherence to: 1) prescription medications for CVD-related risk factors, and 2) surveillance colonoscopy for CRC surveillance. Intervention materials will also address lifestyle choices such as dietary and exercise patterns. This pilot test will elucidate whether the intervention is feasible for CRC survivors and whether short-term medication adherence and intent to undergo colonoscopy be attained. A self- management intervention targeted to this unique patient population will improve survivorship care quality.