Chemotherapy Near Death: Modifiable Factors and Outcomes in Ovarian Cancer

濒临死亡的化疗：卵巢癌的可改变因素和结果

• 批准号: 8508591
• 负责人: Alexi A Wright
• 金额: $ 17.71万
• 依托单位: DANA-FARBER CANCER INST
• 依托单位国家: 美国
• 财政年份: 2013
• 资助国家: 美国
• 起止时间: 2013-08-05 至 2018-07-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8508591
• 关键词: Advanced Malignant Neoplasm; American Society of Clinical Oncology; Atlases; Behavior; Cancer Patient; Caregivers; Caring; Cessation of life; Cognitive; Dana-Farber Cancer Institute; Data; Data Analyses; Data Sources; Decision Making; Distress; Emotional; Environmental air flow; General Hospitals; Goals; Health; Health system; Healthcare; Influentials; Intervention; Intervention Studies; Life; Link; Malignant Neoplasms; Malignant neoplasm of gastrointestinal tract; Malignant neoplasm of lung; Malignant neoplasm of ovary; Massachusetts; Medical; Medicare; Mentors; Morbidity - disease rate; Oncologist; Outcome; Patient Care; Patient Preferences; Patients; Physicians; Platinum; Provider; Psychosocial Factor; Quality of life; Recurrence; Regimen; Research; Research Personnel; Resistance; Resuscitation; Survey Methodology; Surveys; Terminal Disease; Terminally Ill; Testing; Therapeutic; Training; Uncertainty; base; chemotherapy; cohort; coping; cost; end of life; evidence base; experience; health care service utilization; hospice environment; improved; medical supply; novel; older patient; population based; preference; prognostic; prospective; skills; therapy design

DESCRIPTION (provided by applicant): The use of chemotherapy at the end-of-life (EOL) is increasing, despite growing concerns that it may be burdensome, expensive, and potentially harmful. Between 20-50% of terminally-ill cancer patients receive chemotherapy in the last month of life (henceforth referred to as EOL chemotherapy). Rates are highest in ovarian cancer where patients may respond to multiple lines of chemotherapy, increasing uncertainty about when to stop treatment. Research suggests that EOL chemotherapy is associated with more aggressive EOL care and lower rates of hospice utilization, both of which are associated with worse patient quality of life (QoL) near death, higher costs, and more distress in bereaved caregivers. Recently, the American Society of Clinical Oncology (ASCO) identified EOL chemotherapy first on its "Top Five List" of widely used practices that could improve patient care while reducing costs, if stopped. The determinants of EOL chemotherapy use are poorly understood. Researchers from the Dartmouth Health Care Atlas have argued that cancer patients' EOL care is determined by medical supply factors, not patient preferences. In contrast, we have found that patients' treatment preferences, providers' behaviors, and the therapeutic alliance between patients and oncologists predict the intensity of advanced cancer patients' EOL care, both adjusting for and stratifying by health systems. Most recently, we have found that late-line chemotherapy is one of the most powerful predictors of aggressive EOL care in patients with advanced lung and gastrointestinal cancers. In Coping with Cancer, patients who received late-line chemotherapy, a median of 4.5 months before death, had 8-fold higher odds of undergoing ventilation or resuscitation in the last week of life, compared with patients who did not. These preliminary results highlight the need to determine outcomes of late-line chemotherapy in other cancers, to understand better what factors influence the receipt of EOL chemotherapy, and to develop an intervention to improve EOL care. The overall goals of this project are: a) to examine outcomes of late-line chemotherapy (defined as e2 non- platinum-based regimens) in patients with platinum-resistant ovarian cancer, including whether patients are receiving care that is congruent with their preferences (treatment goal attainment), b) to identify modifiable determinants of EOL chemotherapy use to target in an intervention, and c) to develop an intervention to decrease EOL chemotherapy use. Two complementary data sources will be used for Aims 1&2: 1) a prospective, longitudinal, multi-institutional study of 200 patient with recurrent, platinum-resistant ovarian cancer (Coping with Cancer 2~ CwC2)~ and 2) a population-based cohort of 10,310 older patients with advanced ovarian cancer from SEER-Medicare. In Aim 1, I will use CwC2 data to examine associations between late-line chemotherapy and patient QoL, intensity of EOL care, and goal attainment~ and SEER-Medicare to examine patients' EOL health care utilization and patients' cancer and/or treatment related morbidity. In Aim 2, I will use CwC2's comprehensive information on psychosocial factors to examine modifiable patient and caregiver factors associated with EOL chemotherapy use, paired with a new physician survey which I will develop, refine, test, implement, and link to CwC2 data to identify modifiable physician factors associated with EOL chemotherapy. In Aim 3, I will develop and pilot an intervention at the Dana-Farber Cancer Institute and Massachusetts General Hospital to decrease EOL chemotherapy use, based upon my findings in Aims 1 and 2, which will likely target physicians since they are the most influential determinants of decisions to forgo life-sustaining treatments in other contexts.39 Together, these data will provide an evidence base to improve chemotherapy decision-making, identify novel and modifiable determinants of EOL chemotherapy, and allow me to target the these determinants in an intervention designed to decrease EOL chemotherapy use. The portfolio of proposed analyses, combined with close mentoring and specific training in decision-making, longitudinal data analysis, survey methodology, and intervention research, will equip me with the necessary skills and experience to transition from a mentored research fellow to become a successful, independent researcher.

描述（由申请人提供）：尽管越来越多的人担心化疗可能负担沉重、昂贵且可能有害，但生命末期（EOL）化疗的使用正在增加。20-50%的晚期癌症患者在生命的最后一个月接受化疗（以下称为EOL化疗）。卵巢癌的发病率最高，患者可能对多线化疗有反应，增加了何时停止治疗的不确定性。研究表明，终末期化疗与更积极的终末期护理和更低的临终关怀利用率相关，这两者都与濒临死亡的患者生活质量（QoL）更差、成本更高和丧亲照顾者更痛苦相关。最近，美国临床肿瘤学会（ASCO）将EOL化疗列为其广泛使用的实践的“前五名”，如果停止，可以改善患者护理，同时降低成本。 人们对EOL化疗使用的决定因素知之甚少。来自达特茅斯医疗保健地图集的研究人员认为，癌症患者的终末期护理是由医疗供应因素决定的，而不是患者的偏好。相比之下，我们发现，患者的治疗偏好，提供者的行为，以及患者和肿瘤学家之间的治疗联盟预测晚期癌症患者的EOL护理的强度，都调整和分层的卫生系统。最近，我们发现晚期化疗是晚期肺癌和胃肠道癌患者积极终末期护理的最有力预测因素之一。在《应对癌症》一书中，接受晚期化疗（死亡前中位数为4.5个月）的患者在生命的最后一周接受通气或复苏的几率是接受晚期化疗的患者的8倍。 没有这些初步结果强调需要确定其他癌症的晚期化疗的结果，更好地了解影响接受EOL化疗的因素，并制定干预措施以改善EOL护理。 该项目的总体目标是：a）检查晚期化疗的结果（定义为e2非铂类方案），包括患者接受的治疗是否符合其偏好（治疗目标实现），B）鉴定干预中靶向的EOL化疗使用的可改变的决定因素，和c）开发减少EOL化疗使用的干预。 两个互补的数据源将用于目标1和2：1）一项对200例复发性铂类耐药卵巢癌患者（应对癌症2~ CwC 2）的前瞻性、纵向、多机构研究，2）一项来自SEER-Medicare的10，310例晚期卵巢癌老年患者的基于人群的队列研究。在目标1中，我将使用CwC 2数据来检查晚期化疗与患者QoL、EOL护理强度和目标实现之间的关联，并使用SEER-Medicare来检查患者的EOL医疗保健利用率和患者的癌症和/或治疗相关发病率。在目标2中，我将使用CwC 2关于心理社会因素的综合信息来检查与EOL化疗使用相关的可修改的患者和护理人员因素，并与一项新的医生调查配对，我将开发，完善，测试，实施并链接到CwC 2数据，以确定与EOL化疗相关的可修改的医生因素。在目标3中，我将根据我在目标1和2中的发现，在达纳-法伯癌症研究所和马萨诸塞州总医院开发并试点一项干预措施，以减少EOL化疗的使用，这可能会针对医生，因为他们是在其他情况下放弃维持生命治疗的决定的最有影响力的决定因素。39 总之，这些数据将提供一个证据基础，以改善化疗决策，确定新的和可修改的决定因素的EOL化疗，并允许我针对这些决定因素的干预措施，旨在减少EOL化疗的使用。建议的分析组合，结合决策，纵向数据分析，调查方法和干预研究的密切指导和具体培训，将使我具备必要的技能和经验，从一个指导研究员过渡到成为一个成功的，独立的研究人员。