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)是美国第二大癌症死亡原因。筛查减少 发病率和死亡率，部分原因是发现和切除了息肉，如腺瘤。指导方针 建议在腺瘤摘除(息肉切除术)后监测结肠镜检查，但 息肉切除术后降低结直肠癌风险的监测尚不确定。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。与以下内容相关的危害 结肠镜检查随年龄增长而显著增加。老年人不太可能活得足够长而受益于 由于竞争的非结直肠癌死亡风险，如监视结肠镜检查等干预措施。这口井- 已确定的与年龄相关的死亡原因和结肠镜检查相关损害的风险增加 与主要证据差距形成鲜明对比；目前尚不清楚结直肠癌风险在临床上是否显著 有息肉病史的老年人，以及让老年人接受监测是否会降低结直肠癌风险。 然而，默认的临床模式是许多老年人接受监视结肠镜检查。重要意义：在 退伍军人事务部(VA)的监测是结肠镜检查的一个非常常见的适应症 年长的退伍军人，估计每年有17,400人受到监视。可用数据之间的不匹配 证据和目前的临床实践，加上退伍军人事务部结肠镜检查资源的极端限制 使监视结肠镜检查范例成为量化风险和收益的理想重点领域，以便 优化健康结果。创新与影响：在既往有结直肠癌史的老年人中确定结直肠癌风险 息肉切除术和与监测相关的结果将填补关键证据空白。多方利益相关者 对儿童权利中心风险和监测结果的看法将为未来实施证据铺平道路-- 基于、以退伍军人为中心和优化价值的老年人监测战略。这项工作还将 作为利用退伍军人管理局数据来解决退伍军人管理局大型企业面临的重要人口健康挑战的模型 以及如何利用这些数据让退伍军人参与进来，以优化结果。 具体目标：目标1)比较老年人队列中75岁以后的累积结直肠癌风险与既往 75岁以前的普通结肠镜检查(n=101,328)与结肠镜检查加息肉切除术(n=29,548)比较。假设： 75岁以后发生意外结直肠癌(初级分析)和致命性结直肠癌(二级分析)的累积风险将为 在75岁以前接受正常结肠镜检查与结肠镜下息肉切除术的老年人中类似。 目的2)评估暴露与不暴露于监测的比较有效性，以降低结直肠癌风险。 假设：未暴露于监测的老年人与接受监测的老年人发生结直肠癌的风险相似(主要 分析)和致命性结直肠癌(二级分析)。目标3)获取多层次利益攸关方的观点 结直肠癌风险和监测结果，以指导未来的使用和VA关于监测结肠镜检查的政策 年长的退伍军人。方法：AIM 1将利用先前建立的结肠镜队列进行比较 在有正常结肠镜检查和息肉切除术的老年人中，结直肠癌的风险。AIM 2将使用一个案例- 评估老年人息肉切除术后发生结直肠癌风险的队列设计 暴露于监视结肠镜检查的患者与未暴露的患者相比。目标3将包括对患者的一对一采访 和提供者(目标3a)，并召集由多个利益攸关方(包括患者、提供者、 和退伍军人政策制定者)审查来自目标1、2和3a的数据，并生成监控建议 老年人的结肠镜检查，可以指导退伍军人事务部关于老年人监测的政策。下一步/ 实施：退伍军人事务部内外的指导方针将由以下方面的关于CRC风险的新证据提供信息 既往有息肉切除术的老年人以及暴露于监测对结直肠癌风险结局的影响 关于新证据应该如何为决策和临床实践提供信息的多方利益相关者的观点。