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、昂贵且潜在有害，但在生命末期（EOL）使用化疗的情况正在增加。20-50%的癌症晚期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，患者可能对多种化疗方案有反应，这增加了何时停止治疗的不确定性。研究表明，EOL化疗与更积极的EOL护理和更低的临终关怀使用率相关，这两者都与患者接近死亡的生活质量（QoL）恶化、成本更高以及丧亲照护者更痛苦相关。最近，美国临床肿瘤学会（ASCO）将EOL化疗列为其广泛使用的“五大疗法”之首，如果停止使用，可以改善患者护理，同时降低成本。EOL化疗使用的决定因素尚不清楚。达特茅斯卫生保健地图集的研究人员认为，癌症患者的EOL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与肿瘤学家之间的治疗联盟预测了晚期癌症患者EOL护理的强度，这既包括卫生系统的调整，也包括卫生系统的分层。最近，我们发现晚期化疗是晚期肺癌和胃肠道癌症患者积极EOL治疗的最有力预测因素之一。在应对癌症方面，接受晚期化疗的患者（平均在死亡前4.5个月）在生命最后一周接受通气或复苏的几率是接受化疗的患者的8倍