Surveillance Colonoscopy in Older Adults: The SurvOlderAdults Study

老年人结肠镜检查监测：SurvOlderAdults 研究

• 批准号: 10638065
• 负责人: Samir Gupta
• 金额: --
• 依托单位: VA SAN DIEGO HEALTHCARE SYSTEM
• 依托单位国家: 美国
• 财政年份: 2023
• 资助国家: 美国
• 起止时间: 2023-10-01 至 2027-09-30
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10638065
• 关键词: Address; Adult; Age; Area; Benefits and Risks; Cancer Etiology; Caring; Cessation of life; Clinical; Colonoscopy; Colorectal Cancer; Coupled; Data; Decision Making; Deimplementation; Detection; Diagnosis; Elderly; Emergency Situation; Excision; Exposure to; Future; Gastroenterologist; Geriatrics; Goals; Guidelines; Health; Health Personnel; Hospitalization; Incidence; Intervention; Interview; Knowledge; Malignant Neoplasms; Methodology; Modeling; Outcome; Patients; Policies; Policy Maker; Polypectomy; Polyps; Population; Primary Care; Provider; Recommendation; Recording of previous events; Research; Resources; Risk; Risk Reduction; Sampling; Structure; United States; United States Department of Veterans Affairs; United States Preventative Services Task Force; Veterans; Visit; Work; adenoma; age related; clinical practice; clinically significant; cohort; colon growth; colorectal cancer risk; colorectal cancer screening; comparative effectiveness; design; evidence base; experience; future implementation; health goals; high risk; innovation; mortality; mortality risk; novel; population health; primary outcome; screening; secondary analysis; stakeholder perspectives; surveillance strategy; young adult

Background: Colorectal cancer (CRC) is the 2nd leading cause of cancer death in the US. Screening reduces incidence and mortality, in part due to detection and removal of polyps such as adenomas. Guidelines recommend surveillance colonoscopy after adenoma removal (“polypectomy”), but incremental benefit of surveillance after polypectomy on reducing CRC risk is uncertain. For adults age 75 and older (“older adults”) considering surveillance colonoscopy, these issues are of particular importance. Harms associated with colonoscopy increase dramatically with age. Older adults are less likely to live long enough to benefit from interventions such as surveillance colonoscopy due to competing non-CRC mortality risks. The well- established age-related increasing risks for competing causes of mortality and colonoscopy-related harms stand in sharp contrast to major evidence gaps; it is unclear whether CRC risk is clinically significant among older adults with prior history of polyps, and whether exposing older adults to surveillance reduces CRC risk. Yet, the default clinical paradigm is for many older adults to receive surveillance colonoscopy. Significance: In the Department of Veterans Affairs (VA), surveillance is a very common indication for colonoscopy among older Veterans, with an estimated 17,400 exposed to surveillance annually. The mismatch between available evidence and current clinical practice, coupled with extreme constraints on colonoscopy resources in the VA make the surveillance colonoscopy paradigm an ideal focus area for quantifying risks and benefits in order to optimize health outcomes. Innovation & Impact: Establishing CRC risk among older adults with prior polypectomy and outcomes associated with surveillance will fill critical evidence gaps. Multi-stakeholder perspectives on CRC risk and surveillance outcomes will pave the way for future implementation of evidence- based, Veteran-centric, and optimized-value strategies for surveillance among older adults. This work will also serve as a model for leveraging VA data to address an important population health challenge for the VA’s large and growing older adult population and how to use these data to engage Veterans to optimize outcomes. Specific Aims: Aim 1) Compare cumulative CRC risk after age 75 in a cohort of older adults with history of normal colonoscopy (n=101,328) vs. colonoscopy with polypectomy (n=29,548) prior to age 75. Hypothesis: Cumulative risk for incident CRC (primary analysis) and fatal CRC (secondary analysis) after age 75 will be similar among older adults who had normal colonoscopy vs. colonoscopy with polypectomy prior to age 75. Aim 2) Assess comparative effectiveness of exposure vs. no exposure to surveillance for reducing CRC risk. Hypothesis: Older adults unexposed vs. exposed to surveillance will have similar risk for incident CRC (primary analysis) and fatal CRC (secondary analysis). Aim 3) Obtain multi-level stakeholder perspectives regarding CRC risk and surveillance outcomes to inform future use and VA policy regarding surveillance colonoscopy in older Veterans. Methodology: Aim 1 will leverage a previously established colonoscopy cohort to compare risk for CRC among older adults with prior normal colonoscopy vs. polypectomy. Aim 2 will employ a case- cohort design to evaluate risk for CRC (cases) among older adults with prior polypectomy subsequently exposed vs. unexposed to surveillance colonoscopy. Aim 3 will include one-on-one interviews with patients and providers (Aim 3a) and convening an expert panel of multiple stakeholders (including patients, providers, and VA policymakers) to review data from Aims 1, 2, and 3a and generate recommendations for surveillance colonoscopy in older adults that can guide VA policy around surveillance among older adults. Next Steps/ Implementation: Guidelines within and outside VA will be informed by the novel evidence on CRC risk among older adults with prior polypectomy and impact of exposure to surveillance on CRC risk outcomes, as well as multi-stakeholder perspectives on how new evidence should inform decision-making and clinical practice.

背景：结直肠癌（CRC）是美国癌症死亡的第二大原因。筛查减少 发病率和死亡率，部分原因是息肉如腺瘤的检测和切除。准则 建议在腺瘤切除术（“息肉切除术”）后进行监测结肠镜检查， 息肉切除术后对降低结直肠癌风险的监测尚不确定。对于75岁及以上的成年人（“老年人”） 考虑到监视结肠镜检查，这些问题特别重要。相关损害 结肠镜检查随着年龄的增长而显著增加。老年人不太可能活得足够长， 由于竞争性非CRC死亡风险，因此需要采取诸如监测结肠镜检查等干预措施。井- 确定年龄相关的竞争性死亡原因和结肠镜检查相关危害的风险增加 与主要证据缺口形成鲜明对比;目前尚不清楚CRC风险是否具有临床意义， 有息肉病史的老年人，以及老年人接受监测是否会降低CRC风险。 然而，默认的临床模式是许多老年人接受监测结肠镜检查。意义：在 根据退伍军人事务部（VA），监测是结肠镜检查的一个非常常见的指征， 老年退伍军人，估计每年有17，400人受到监视。现有的 证据和当前的临床实践，加上VA中结肠镜检查资源的极端限制 使监测结肠镜检查范式成为量化风险和获益的理想重点领域， 优化健康结果。创新与影响：在既往患有CRC的老年人中确定CRC风险 息肉切除术和与监测相关的结果将填补关键的证据空白。多方利益 对CRC风险和监测结果的看法将为未来实施证据铺平道路- 为基础的，退伍军人为中心的，和优化的价值策略，在老年人中的监测。这项工作还将 作为一个模型，利用退伍军人事务部数据，以解决一个重要的人口健康挑战，为退伍军人事务部的大 和不断增长的老年人口，以及如何使用这些数据来吸引退伍军人，以优化结果。 具体目的：目的1）比较75岁后有结直肠癌病史的老年人队列中的累积CRC风险。 正常结肠镜检查（n= 101，328）与结肠镜检查伴息肉切除术（n= 29，548）在75岁之前。假设： 75岁以后发生CRC（主要分析）和致死性CRC（次要分析）的累积风险将 在75岁之前进行正常结肠镜检查与结肠镜检查伴息肉切除术的老年人中相似。 目的2）评估暴露与不暴露监测降低CRC风险的比较有效性。 假设：未暴露于监测的老年人与暴露于监测的老年人发生CRC的风险相似（主要 分析）和致死性CRC（次要分析）。目标3）获得多层次利益攸关方的观点， CRC风险和监测结果，以告知未来的使用和VA政策，关于监测结肠镜检查， 老退伍军人方法：Aim 1将利用之前建立的结肠镜检查队列进行比较 既往结肠镜检查正常与息肉切除术的老年人中CRC的风险。目标2将采用一个案例- 队列设计，以评估既往息肉切除术后老年人的CRC风险（病例） 暴露与未暴露于监测结肠镜检查。目标3将包括与患者的一对一访谈 和提供者（目标3a），并召集多个利益攸关方（包括患者，提供者， 和VA决策者）审查目标1、2和3a的数据，并提出监测建议 老年人结肠镜检查可以指导老年人监测的VA政策。后续步骤/ 实施：VA内部和外部的指南将通过以下关于CRC风险的新证据进行通报： 既往息肉切除术的老年人和暴露于监测对CRC风险结局的影响，以及 多方利益相关者对新证据如何为决策和临床实践提供信息的观点。