Patient-Centered Decision-Making for Management of Small Renal Tumors

 描述（由申请人提供）：尽管早期发现和积极治疗（手术切除），但目前小肾肿瘤（≤ 4 cm）的治疗模式导致总生存期恶化。这种缺乏改善的结果可能是由于大多数肾脏肿瘤的无痛性和手术在这一普遍老年人群中的危害。虽然大多数这些小的肾脏肿块是恶性的，少数肿瘤转移，约20%是良性的。必须在决策中更广泛地采用不太积极的治疗方案，以防止惰性或良性肿瘤患者进行不必要的手术，或手术后结果不佳的风险因素。 作为一名腹部放射科医生和健康结果研究员，我已经获得了医学博士学位，并正在攻读科学硕士学位，专注于比较有效性研究方法。我是一个放射学成果研究基金的PI，以评估最近开发的功能性磁共振成像（MRI）技术，以表征肾脏肿块并帮助治疗选择。纽约大学医学中心的人口健康和放射学部门提供指导和资源，使我能够作为独立研究者成功地进行肾脏肿块管理方面的卫生服务研究。医疗决策，决策辅助，放射学，肿瘤学和泌尿学专家团队将指导我的项目和职业发展。我将完成高级决策分析建模，决策辅助开发和调查研究的课程，以建立我的项目所需的技能，以及我的职业生涯。 在拟议的工作中，我将总结肾肿瘤表征的诊断成像测试的性能特点。我将构建一个决策分析模型，以评估肿瘤成像特征的下游肿瘤学和治疗后结局，并纳入可能影响长期生存的患者合并症（例如慢性肾脏疾病）。经过测试的治疗策略包括目前的护理标准肾部分切除术，以及微创经皮消融和观察等待。然后，我将在交互式决策辅助中嵌入决策模型，以提高患者对小型肾肿瘤的了解，传达个性化的危害/益处，并在治疗选择中引出患者偏好。我假设1）MRI在检测良性肾肿瘤和惰性恶性肿瘤方面的特异性高于CT; 2）结合小肾肿瘤组织学和解剖学以及患者合并症与标准管理相比，治疗选择（包括肾功能）可改善预期寿命;和3）与目前的外科手术标准相比，观察等待和消融对于目前未提供这些策略的大多数患者的生存是非劣效策略。这些贡献将提供一个及时和新颖的工具， 确定最有效的治疗方法，并增加以患者为中心的决策，以管理小型肾肿瘤。

 DESCRIPTION (provided by applicant): The current treatment paradigm for small renal tumors (≤ 4 cm) has resulted in worsened overall survival despite earlier detection and aggressive treatment with surgical resection. This lack of improved outcomes may be due to the indolence of most renal tumors and harms of surgery in this generally elderly population. Although the majority of these small renal masses are malignant, a small minority of tumors metastasize and approximately 20% are benign. Less aggressive treatment alternatives must be more widely adopted into decision-making to prevent unnecessary surgeries in patients with indolent or benign tumors, or risk factors for poor post-surgical outcomes. As an abdominal radiologist and health outcomes researcher, I have obtained my MD and am pursuing a Master of Science concentrated in comparative effectiveness research methods. I am PI on a radiology outcomes research grant to evaluate recently developed functional magnetic resonance imaging (MRI) techniques to characterize renal masses and aid in treatment selection. The Departments of Population Health and Radiology within New York University Medical Center offer the mentoring and resources to position me for successful health services research in renal mass management as an independent investigator. A team of experts in medical decision-making, decision aids, radiology, oncology and urology will guide my project and career development. I will complete coursework in advanced decision-analytic modeling, decision aid development, and survey research to build the skillset required for my project, as well as my career. In the proposed work, I will summarize performance characteristics of diagnostic imaging tests for renal tumor characterization. I will construct a decision-analytic model to assess downstream oncologic and post- treatment outcomes of tumor imaging features, incorporating patient comorbidities (e.g. chronic kidney disease) that may impact long-term survival. Tested treatment strategies include the current standard of care partial nephrectomy, as well as less invasive percutaneous ablation and watchful waiting. I will then embed the decision model in an interactive decision aid to improve patients' knowledge of small renal tumors, communicate personalized harms/benefits, and elicit patient preferences in treatment selection. I hypothesize that 1) MRI will perform with higher specificity than CT for detection of benign renal tumors and indolent malignancies; 2) incorporation of small renal tumor histology and anatomy, and patient comorbidities (including renal function) in treatment selection improves life expectancy compared with standard management; and 3) watchful waiting and ablation are non-inferior strategies for survival compared with the current standard of surgery in most patients who are not currently offered these strategies. These contributions will provide a timely and novel tool to determine the most effective treatment and increase patient-centered decision-making for management of small renal tumors.