Incorporating Veterans' Preferences into Lung Cancer Screening Decisions

肺癌是美国癌症死亡的主要原因。最近的临床试验提供了证据 使用低剂量CT扫描进行筛查将减少肺癌，并在老年重型患者中导致全部死亡 吸烟者。USPSTF已经发布了临床指南，建议从55岁起每年进行筛查 对于那些吸烟30年或更长时间或戒烟不到15年的人来说，最高可达80岁。清晰的证据 描述了益处(降低死亡率)和危害(假阳性、后续检测、侵入性风险 检测和过度诊断的风险)肺癌筛查。来自HSR&D试点拨款的初步数据发现 一些退伍军人非常不愿意进入与肺癌筛查相关的护理途径 它的潜在危害。在老年吸烟者中使用最佳最差比例的其他初步数据表明 在考虑肺癌时，更看重伤害而不是益处的患者群体 放映。偏好评估方法可以帮助退伍军人权衡利弊，考虑到 他们正在进入的临床路径，预测未来的健康状态，并将这些价值传达给他们的健康 照顾者。尽管为肺癌决策提供信息的基本教育工具已经开发出来， 缺乏可以整合到临床环境中的经过验证的偏好评估工具。建房 根据在HSR&D试点赠款(PI-Schapira)中开发和验证的偏好评估方法和 使用跨学科的方法，这个团队的定位是推进决策的科学和实践 支持在退伍军人中进行肺癌筛查。这项研究的目的是1)引出 患者和提供者利益相关者的意见，为肺癌筛查决策工具的开发提供信息，2) 开发一个基于Web的肺癌筛查决策工具(LCSDecTool)，它结合了患者和 提供者输入，以及3)评估LCSDecTool与通常护理相比对决策过程的影响， 临床结果和生活质量。研究将分三个阶段进行。在第一阶段，混合方法将 用于评估偏好评估方法的可用性和基于网络的肺的感知有用性 患者和提供者利益相关者之间的癌症筛查决策支持工具。在阶段2中，交互式 将开发包含偏好评估方法的基于网络的决策支持程序。在……里面 第三阶段，将进行一项试点随机对照试验，以评估基于网络的决策支持方案的效果。 评估的结果将包括由知识、决策冲突和决策指示的决策质量 后悔、筛查行为、焦虑所指示的临床结果和生活质量。这项研究将是 在两个退伍军人事务部进行；康涅狄格州的West Haven-VA和弗吉尼亚州的下士Michael J.Cresenz 宾夕法尼亚州费城。这项研究的结果将提供可用于整合肺癌的工具 在退伍军人医学中心以患者为中心进行临床筛选。肺癌筛查 在几个方面与现有的筛选范例有根本的不同；资格由 行为(吸烟)，预计假阳性结果的比率很高，并且目标人群年龄较大 宫颈、乳房或结直肠筛查的合并症高于目标人群。鉴于这些独一无二的 在肺癌筛查的各个方面，迫切需要开发和测试偏好评估工具 以及适用于退伍军人事务部设置的知情决策。目前的提案提供了一个 实现这些目标的机制。首席调查员正在与美国司法部密切合作 退伍军人事务部国家健康促进和疾病预防中心将工具和 在退伍军人医疗保健系统中发展为初级保健的范例。这项工作直接建立在最近的一项 完成了肺癌领域的高铁研发试点支持和共同决策。

Lung cancer is the leading cause of cancer deaths in the United States. Recent clinical trials provide evidence that screening with low dose CT scans will decrease lung cancer and all cause mortality among older heavy smokers. Clinical guidelines have been issued with the USPSTF recommending annual screening from age 55 to 80 for those with 30 pack years or more of smoking or who quit less than 15 years ago. Evidence clearly delineates both the benefits (mortality reduction) and harms (false positives, follow-up testing, risk of invasive testing, and risk of overdiagnosis) of lung cancer screening. Preliminary data from an HSR&D pilot grant finds that some Veterans are highly reluctant to enter the care pathway associated with lung cancer screening due to its potential harms. Additional preliminary data using Best Worst Scaling in older smokers demonstrate groups of patients who place greater importance on harms than benefit when considering lung cancer screening. Preference assessment methods can help Veterans to weigh benefits and harms, consider the clinical pathway they are entering, anticipate future health states, and communicate these values to their health care providers. Although basic educational tools to inform lung cancer decision-making have been developed, there is a lack of validated preference assessment tools that can be integrated into the clinical setting. Building upon preference assessment methods developed and validated in an HSR&D pilot grant (PI-Schapira) and using a trans-disciplinary approach, this team is positioned to advance the science and practice of decision support for lung cancer screening in the Veteran population. The objectives of this study are to 1) elicit patient and provider stakeholder input to inform the development of a lung cancer screening decision tool, 2) develop a web based Lung Cancer Screening Decision Tool (LCSDecTool) that incorporates patient and provider input, and 3) evaluate the impact of the LCSDecTool compared to usual care on the decision process, clinical outcomes, and quality of life. The study will be conducted in 3 phases. In phase 1, mixed methods will be used to assess usability of preference assessment methods and perceived usefulness of a web based lung cancer screening decision support tool among patient and provider stakeholders. In phase 2, an interactive web based decision support program will be developed that incorporates preference assessment methods. In phase 3, a pilot RCT will be conduced to evaluate the efficacy of the web based decision support program. Outcomes evaluated will include decision quality as indicated by knowledge, decisional conflict, and decision regret; screening behavior, clinical outcomes as indicated by anxiety, and quality of life. The study will be conducted across two VA sites; West Haven-VA in Connecticut and Corporal Michael J. Crescenz VA in Philadelphia, Pennsylvania. Results of this study will provide tools that can be used to integrate lung cancer screening into clinical practice at VA Medical Centers in a patient centered approach. Lung cancer screening is fundamentally different from existing screening paradigms in several respects; eligibility is defined by a behavior (smoking), a high rate of false positive findings is expected, and the target population is older with higher comorbidity than the target population for cervical, breast, or colorectal screening. Given these unique aspects of lung cancer screening, there is a critical need to develop and test tools for preference assessment and informed decision making that are applicable for the VA setting. The current proposal provides a mechanism to accomplish these goals. The Principal Investigator is working closely with the US Department of Veterans Affairs National Center for Health Promotion and Disease Prevention to integrate the tools and paradigm developed to primary care in the VA Medical Care System. The work builds directly upon a recently completed HSR&D pilot support in the area of lung cancer and shared decision making.