Use of a decision aid to resolve uncertainty about radioactive iodine treatment in patients with intermediate-risk thyroid cancer: the Radiance trial

抽象的。被诊断为中风险分化型甲状腺癌(DTC)的个人遇到 关于放射性碘(RAI)的风险和益处的重大不确定性。RAI是一种常规治疗方法 根据记录的存活率增加的高危DTC患者。相比之下，RAI通常是 不适用于低风险DTC患者，因为它不能减少复发或提高存活率。由于 由于缺乏随机对照试验的数据，关于利益和 中危DTC患者接受RAI治疗的风险。临床实践指南现在建议 中危疾病患者应考虑RAI。因此，大多数患有中度风险DTC的患者 在单独手术和手术加RAI之间做出选择。我们团队和其他人的数据表明，患者报告说 缺乏关于RAI潜在副作用的信息，包括唾液腺损伤、鼻腔和泪水 症状、生殖影响、继发性恶性肿瘤以及对生活质量的影响。唾液腺损伤 发生在21-77%的RAI后的患者中，呈剂量依赖性。其他RAI剂量依赖效应 包括泪水和鼻部症状。患者还报告说，疲劳加剧，生活质量下降， 尤其是RAI的并发症。患有中度风险DTC的患者需要平衡 了解RAI的风险和好处。使用有关RAI优势和令人信服的既定数据 关于RAI副作用频率的新数据，我们寻求开发和评估决策辅助(DA) 在这些患者中促进对RAI治疗的知情决定。在渥太华决定的指导下 在支持框架中，我们将首先开发和试点测试DA(UG3目标1)。我们将使用初步数据，团队 为制定发展议程大纲而提供的投入和出版的指南。我们将开发一个基于Web的原型并 对16名患者(8名有RAI，8名没有RAI)进行可用性测试。我们将修改DA并招募30名患者 使用新诊断的中等风险DTC进行DA的试点随机对照试验，以检查 发展议程的可行性、可用性和满意度。我们将DA(n=20)与常规护理(UC)进行比较 教育控制网站(n=10)，以探索DA对关于RAI、知识、 随机化后4周的自我效能感、决策冲突和后悔。我们将进行迭代 对地方检察官的改进。在UH3阶段(3-7年；UH3目标2、3)，我们将进行多点随机 在三个临床地点对最终的DA进行对照试验。我们将筛查800名新诊断为 中等风险DTC，并登记和随机选择400名患者(200名DA组；200名UC组)。我们将进行 在基线和随机化后1周、4周和6个月进行评估。我们的主要结果是 4周后进行知情选择(目标2)。次要结果包括知识、决策冲突和后悔， 和治疗满意度。我们将在6个月时对所有患者的生活质量进行调查。我们将检查自己是否 疗效和对医患沟通的满意度对DA的效果起中介作用(目标3)。

ABSTRACT. Individuals diagnosed with intermediate risk differentiated thyroid cancer (DTC) encounter significant uncertainty regarding the risks and benefits of radioactive iodine (RAI). RAI is routine treatment for patients with high risk DTC based on the documented increased rate of survival. In contrast, RAI is generally not used for patients with low risk DTC, as it does not decrease recurrence nor increase survival. Due to absence of data from randomized controlled trials, controversy remains regarding the balance of benefits and risks for RAI treatment for patients with intermediate risk DTC. Clinical practice guidelines now suggest consideration of RAI in patients with intermediate risk disease. Thus, most patients with intermediate risk DTC choose between surgery alone vs surgery plus RAI. Data from our team and others indicate patients report a lack of information about the potential side effects of RAI including salivary gland damage, nasal and lacrimal symptoms, reproductive impact, secondary malignancies, and effects on quality of life. Salivary gland damage occurs among 21-77% of patients after RAI in a dose-dependent manner. Other RAI-dose dependent effects include lacrimal and nasal symptoms. Patients also report increased fatigue and decreased quality of life, particularly with complications from RAI. Patients with intermediate risk DTC have a need to balance what is known about the risks and benefits of RAI. Using established data concerning RAI benefits and compelling new data about the frequency of side effects due to RAI, we seek to develop and evaluate a decision aid (DA) to promote informed decisions about RAI treatment among these patients. Guided by the Ottawa Decision Support Framework, we will first develop and pilot test the DA (UG3 Aim 1). We will use preliminary data, team input and published guidelines to create an outline of the DA. We will develop a web-based prototype and conduct usability testing with 16 patients (8 with, 8 without RAI). We will revise the DA and recruit 30 patients with newly diagnosed intermediate risk DTC for a pilot randomized controlled trial of the DA to examine the feasibility, usability and satisfaction with the DA. We will compare the DA (n=20) to a usual care (UC) educational control website (n=10) to explore the effect of the DA on informed choice about RAI, knowledge, self-efficacy, and decisional conflict and regret at 4 weeks post-randomization. We will make iterative refinements to the DA. In the UH3 phase (years 3-7; UH3 Aims 2, 3), we will conduct a multi-site randomized controlled trial of the finalized DA at three clinical sites. We will screen 800 patients with newly diagnosed intermediate risk DTC and enroll and randomize 400 patients (n=200 DA arm; n=200 UC arm). We will conduct assessments at baseline and 1 week, 4 weeks and 6 months post-randomization. Our primary outcome is informed choice at 4 weeks (Aim 2). Secondary outcomes include knowledge, decisional conflict and regret, and treatment satisfaction. We will explore QOL among all patients at 6 months. We will examine whether self- efficacy and satisfaction with patient-physician communication mediate the effect of the DA (Aim 3).