Locoregional Treatment Decision-making in Older Adults with Early-Stage, Hormone Receptor-Positive Breast Cancer

患有早期激素受体阳性乳腺癌的老年人的局部治疗决策

• 批准号: 10300711
• 负责人: Christina A Minami
• 金额: $ 12.9万
• 依托单位: BRIGHAM AND WOMEN'S HOSPITAL
• 依托单位国家: 美国
• 财政年份: 2021
• 资助国家: 美国
• 起止时间: 2021-08-01 至 2023-04-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10300711
• 关键词: Affect; American Society of Clinical Oncology; Award; Axilla; Axillary lymph node group; Breast; Breast Cancer Treatment; Breast-Conserving Surgery; Caring; Clinical; Complex; Consumption; Data; Data Set; Decision Making; Development; Diagnosis; Discourse analysis; Disease; Elderly; Evaluation; Face; Foundations; Future; Goals; Guidelines; Hemorrhage; Intervention; K-Series Research Career Programs; Knowledge; Language; Life Expectancy; Lymphedema; Malignant Neoplasms; Mastectomy; Measures; Medical Oncologist; Medicare; Mentorship; Methodology; Minority; Modeling; Nature; Oncology; Outcome; Patient Care; Patient Preferences; Patients; Physicians; Population; Process; Professional Organizations; Radiation; Radiation Oncologist; Radiation therapy; Recommendation; Recurrence; Research; Research Personnel; Risk; Surgeon; Surgical Oncologist; Surgical Wound Infection; Testing; Time; Training; Typology; Variant; Woman; Work; base; career; chronic pain; clinical encounter; design; frailty; functional status; hormone receptor-positive; improved; individual patient; malignant breast neoplasm; older patient; older women; overtreatment; preference; provider factors; shared decision making; skills; surgical risk

Project Summary/Abstract Over 83,000 new breast cancer cases are diagnosed annually in the U.S in women >70 years, and most of these women have early-stage, hormone receptor-positive (HR+) disease. Overtreatment of these women is a growing concern, as existing data demonstrate that less-intense locoregional therapy (i.e. de-escalated therapy) does not decrease overall survival. It is well-established that mastectomy does not confer a survival benefit over breast-conserving surgery (BCS), and emerging trial data also support safe omission of radiation therapy (RT) and axillary lymph node evaluation. Proceeding with RT and axillary lymph node evaluation comes with an increased risk of surgical site infection, bleeding, chronic pain, lymphedema, and radiation-induced malignancy. Omitting these treatments, however, may be associated with a small increase in locoregional recurrence. These women thus face complex treatment decisions, which can be further complicated by the presence of geriatric-specific concerns, such as frailty, life expectancy, functional status, and competing risks. Though oncologic professional societies endorse integration of geriatric-specific concerns into treatment decision-making, it is unclear to what extent physicians heed this recommendation. Shared decision making (SDM) reinforces the importance of patient autonomy, can facilitate high-quality decisions (defined as knowledgeable decisions that are concordant with patient values), and can help to reduce overtreatment. SDM, however, can also be a difficult and time-consuming process, and existing data hold that few physicians consistently attempt to involve patients in decision making, and even fewer adjust care to patient concerns and preferences. Given the observed decisional difficulty faced by older adults with early-stage HR+ breast cancer, there is a critical need to understand how SDM can be improved in this population. This GEMSSTAR application seeks support for preliminary work aimed at understanding how geriatric-specific concerns are integrated into treatment decision-making, both on a population-level and at the level of patient-physician conversations. My research aims are to: 1) determine factors associated with physician-level and regional variation in the receipt of de-escalated locoregional treatment of older adults with early-stage HR+ breast cancer using SEER-Medicare data, and 2) detail how geriatric-specific concerns (e.g. frailty, life expectancy, functional status, and competing risks) are currently integrated into treatment conversations and to create patient-physician interaction typologies by using discourse analysis to analyze audio-recorded clinical encounters between older adults with early-stage, HR+ breast cancer and surgical, medical, and radiation oncologists. Completion of these aims will set a strong foundation for future studies exploring the complex interplay of patient and physician factors in effective SDM and for targeted interventions aimed at modulating patient-physician interactions to improve decisional quality for older women with early stage breast cancer. This work will, in turn, reduce overtreatment and improve patient care. In addition, this award would provide me with the support, mentorship, training, and networking I need to become a national leader in the study and improvement of treatment decision-making, clinical outcomes, and oncologic outcomes, in older adults with breast cancer.

项目总结/摘要 在美国，每年有超过83，000例新的乳腺癌病例在>70岁的女性中被诊断出来，其中大多数 女性患有早期激素受体阳性（HR+）疾病。对这些妇女的过度治疗越来越令人担忧， 由于现有数据表明，强度较低的局部治疗（即减量治疗）总体上不会降低 生存众所周知，乳房切除术并不比保乳手术（BCS）更有利于生存， 新出现的试验数据也支持放射治疗（RT）和腋窝淋巴结评估的安全省略。 进行RT和腋窝淋巴结评估会增加手术部位感染、出血的风险， 慢性疼痛、水肿和辐射诱发的恶性肿瘤。然而，忽略这些治疗可能与 局部复发率略有增加。因此，这些妇女面临着复杂的治疗决定， 由于存在老年人特有的问题，如虚弱、预期寿命、功能状态， 竞争风险。尽管肿瘤专业协会支持将老年人特有的问题纳入治疗， 决策，目前还不清楚医生在多大程度上听从这一建议。 共享决策（SDM）加强了患者自主权的重要性，可以促进高质量的 决策（定义为与患者价值观一致的知识性决策），并有助于减少 过度治疗然而，SDM也可能是一个困难和耗时的过程，现有数据很少 医生总是试图让病人参与决策，更少的医生根据病人的担忧调整护理， 喜好鉴于观察到的早期HR+乳腺癌老年人面临的决策困难， 迫切需要了解如何在这一人群中改进SDM。 该GEMSSTAR应用程序寻求支持的初步工作，旨在了解如何老年人的具体 在人群水平和患者-医生水平上，将关注事项纳入治疗决策 对话。我的研究目的是：1）确定与医生水平和地区差异相关的因素， 使用SEER-Medicare对患有早期HR+乳腺癌的老年人进行降级局部区域治疗 数据，2）详细说明老年人特有的问题（如虚弱、预期寿命、功能状态和竞争风险） 目前已整合到治疗对话中，并通过使用话语创建患者-医生互动类型 分析早期、HR+乳腺癌老年人和 外科、内科和放射肿瘤学家。这些目标的完成将为今后的研究奠定坚实的基础 探索患者和医生因素在有效SDM中的复杂相互作用，并进行针对性干预， 调节患者与医生的互动，以提高早期乳腺癌老年妇女的决策质量。 这项工作将反过来减少过度治疗和改善病人护理。此外，这个奖项将为我提供 支持，指导，培训和网络，我需要成为研究和改进的国家领导人， 治疗决策，临床结果和肿瘤学结果，在老年乳腺癌患者。