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 低剂量CT扫描筛查将减少肺癌和所有导致老年重 吸烟者。USPSTF已经发布了临床指南，建议从55岁开始每年进行一次筛查 对于那些吸烟30包年或以上或戒烟不到15年的人来说，证据清楚地 描述了益处（死亡率降低）和危害（假阳性，随访测试，侵入性风险） 检测和过度诊断的风险）的肺癌筛查。HSR&D试点赠款的初步数据发现， 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量表的其他初步数据表明， 在考虑肺癌时，更重视危害而不是益处的患者群体 筛选偏好评估方法可以帮助退伍军人权衡利益和危害， 他们正在进入的临床路径，预测未来的健康状态，并将这些价值观传达给他们的健康 护理提供者。虽然已经开发了告知肺癌决策的基本教育工具， 缺乏可以整合到临床环境中的有效的偏好评估工具。建筑 在HSR&D试点补助金（PI-Schapira）中开发和验证的优先评估方法， 该团队采用跨学科的方法，致力于推进决策的科学和实践 支持退伍军人肺癌筛查。本研究的目的是1）引出 患者和提供者利益相关者的输入，以告知肺癌筛查决策工具的开发，2） 开发一个基于网络的肺癌筛查决策工具（LCSDecTool），将患者和 提供者输入，以及3）评估LCSDecTool与常规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3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 癌症筛查决策支持工具之间的患者和供应商利益相关者。在第二阶段， 将开发基于网络的决策支持程序，其中包括偏好评估方法。在 第三阶段，将进行一项试验性随机对照试验，以评估基于网络的决策支持程序的有效性。 评估的结果将包括由知识、决策冲突和决策所指示的决策质量。 遗憾;筛查行为，焦虑所指示的临床结果，以及生活质量。本研究将 在两个VA站点进行;康涅狄格州的West Haven-VA和 宾夕法尼亚州，费城。这项研究的结果将提供工具，可用于整合肺癌 在VA医疗中心以患者为中心的方法进行临床实践筛选。肺癌筛查 在几个方面与现有的筛选模式有根本的不同;资格由 行为（吸烟），假阳性结果的高比率是预期的，目标人群是老年人， 与宫颈、乳腺或结直肠筛查的目标人群相比，合并症更高。鉴于这些独特的 在肺癌筛查方面，迫切需要开发和测试偏好评估工具 以及适用于VA设置的知情决策。目前的建议提供了一个 机制来实现这些目标。首席研究员正在与美国国务院密切合作， 退伍军人事务国家健康促进和疾病预防中心整合这些工具， 在VA医疗保健系统中发展到初级保健的范例。这项工作直接建立在一个最近 完成了肺癌领域的HSR&D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.