Improving decisions about evaluating pulmonary nodules for lung cancer

描述（由申请人提供）：候选人-我是一名肺病学家和健康结果研究人员，专注于肺癌控制和预防。虽然我已经获得了医学博士和公共卫生硕士学位，完成了结果研究的奖学金，并获得了VA HSR&D资助的共同资助，研究潜在癌变肺结节评估中的资源利用，但我将需要进一步的培训和专门的指导，以实现我的职业目标，成为肺癌控制方面的主要研究者。机构——达特茅斯卫生政策和临床实践研究所、共同决策中心、诺里斯·科顿癌症中心和退伍军人事务部结果组为我的研究取得成功提供了资源。项目背景-随着CT扫描的使用越来越多，医生面临着一个越来越常见的诊断挑战——偶发肺结节。人们担心这个结节可能是癌症。在现实中，只有极少数是恶性的，但识别这一部分是困难的，并且涉及到重大的权衡。没有比较治疗策略的随机试验（例如，活组织检查、放射学监测、不作进一步检查），也没有描述肺结节对患者和医生影响的文献。项目目标-系统地研究诊断肺结节对患者和医生的影响，并利用这些信息开发和测试决策辅助工具，以提高对结节的认识，促进共同决策。该项目有三个具体目标：目标一：描述患者对肺结节的理解和经验。为了确定患者对肺结节的信念（包括肺癌风险认知）和管理策略的体验（包括焦虑），我将开发，验证并进行大规模的患者调查。目的二：描述医生对肺结节的看法和处理方法。为了了解医生如何管理、讨论和思考肺结节（包括肺癌的风险），我将对初级保健和肺病医生进行全国代表性的调查。目标III：开发决策辅助工具以改善临床护理，并用于未来的随机试验。综合目标1和目标2的研究结果以及肺结节自然史和治疗的证据，我将创建并测试肺结节患者的决策辅助工具。我将在随后的管理策略的随机比较有效性试验中使用决策辅助来获得知情同意。职业目标：成为癌症控制和预防领域领先的独立研究者，专注于肺结节和肺癌预后。我的导师团队包括调查研究、风险沟通、医疗决策、放射学、肺科、肿瘤学等方面的专家，他们帮助我实现项目目标，并指导我的职业发展。心理测量学、决策学、统计学、癌症控制和基金写作等课程将为我的这个项目和我的职业生涯提供关键技能。公共卫生相关性：肺结节给卫生保健系统带来了巨大的负担，患者和医生可能对其自然史和管理存在重大误解。研究患者和医生对肺结节的看法，以及促进围绕结节管理共同决策的工具，应该是提高这些患者的知识、生活质量和护理的优先事项。

DESCRIPTION (provided by applicant): CANDIDATE - I am a pulmonologist and health outcomes researcher with a focus on lung cancer control and prevention. While I have already received my MD and MPH degrees, completed a fellowship in outcomes research, and have received funding as a Co-PI on a VA HSR&D grant to study resource utilization in evaluation of potentially cancerous pulmonary nodules, I will require further training and dedicated mentorship to achieve my career goal of becoming a leading investigator in lung cancer control. INSTITUTION - The Dartmouth Institute for Health Policy and Clinical Practice, Center for Shared Decision- Making, Norris Cotton Cancer Center, and VA Outcomes Group offer the resources to succeed in my research. PROJECT BACKGROUND - With rising use of CT scans, physicians are faced with an increasingly common diagnostic challenge - the incidental pulmonary nodule. The fear is that the nodule may be cancer. In reality, very few turn out to be malignant, but identifying this subset is difficult and involves significant trade-offs. There are no randomized trials comparing management strategies (e.g., biopsy, radiologic surveillance, no further work-up) and no literature characterizing the impact of pulmonary nodules on patients and doctors. PROJECT OBJECTIVES - To systematically study the impact on patients and physicians of diagnosing pulmonary nodules, and to use this information to develop and test a decision aid to improve knowledge about nodules and promote shared decision-making. The project has 3 specific aims: Aim I: Characterize patients' understanding of and experience with pulmonary nodules. To determine patients' beliefs about pulmonary nodules (including lung cancer risk perception) and experience (including anxiety) with management strategies, I will develop, validate, and conduct a large-scale patient survey. -Aim II: Characterize physicians' beliefs about and management of pulmonary nodules. To learn how physicians manage, discuss, and think about pulmonary nodules (including risk of lung cancer), I will develop and conduct a nationally representative survey of primary care and pulmonary physicians. -Aim III: Develop a decision aid to improve clinical care and to use in a future randomized trial. Synthesizing the findings of Aims I and II with the evidence on pulmonary nodule natural history and management, I will create and test a decision aid for patients with pulmonary nodules. I will use the decision aid to achieve informed consent in a subsequent randomized comparative effectiveness trial of management strategies. CAREER GOALS - To become a leading independent investigator in cancer control and prevention, focusing on pulmonary nodules and lung cancer outcomes. My mentorship team includes experts in survey research, risk communication, medical decision-making, radiology, pulmonology, and oncology to help me achieve my project goals and guide me in my career development. Courses in psychometrics, decision-making, statistics, cancer control, and grant-writing will provide me with key skills for this project and my career. PUBLIC HEALTH RELEVANCE: Pulmonary nodules create a huge burden on the healthcare system, and patients and physicians may have significant misconceptions about their natural history and management. Research on patient and physician views on pulmonary nodules, as well as tools to promote shared decision-making around nodule management should be a priority to improve knowledge, quality of life, and care of these patients.