Cancer and Stress: The Effect of a Cancer Diagnosis on Utilization and Outcomes

描述（由申请人提供）：癌症检测和治疗的进步已经将癌症从短期致命疾病转变为慢性疾病，需要关注长期结果。三分之一到一半的癌症患者经历持续的心理困扰（即抑郁和焦虑）。Distress预测，每位患者每年的医疗保健费用将增加2,000-3,000美元。然而，以前的研究有严重的方法学局限性，包括研究设计仅限于癌症患者随访，强调年轻的成年癌症幸存者，以及狭窄的压力定义，没有纳入包括积极和消极影响措施的全面压力评估。在脆弱的老年癌症患者群体中，不良应激反应与医疗保健利用和健康结果的更广泛程度是未知的。此外，在诊断时帮助识别高危患者的临床工具也不存在。这是一个关键的限制，因为只有不到10%的患者被积极推荐接受支持性服务，这表明癌症相关的压力在临床环境中没有得到充分的解决。本研究的目的是：(1)评估癌症诊断前后心理压力症状的增加幅度；(2)确定在癌症诊断时是否可以识别出有高或持续应激反应风险的患者；(3)评估应激症状增加对患者医疗保健利用和健康结局的影响。威斯康星纵向研究（WLS）的数据被用来实现这些目标。威斯康星纵向研究（WLS）是一项长期研究，随机抽取了三分之一的威斯康星高中毕业生和随机选择的兄弟姐妹（n= 7113）。11%的WLS受访者是癌症幸存者。分析计划通过利用WLS研究设计（纵向数据，非癌症对照组的可用性，以及配对的兄弟姐妹受访者）以及与威斯康星州肿瘤登记处（1979-2006）和医疗保险数据库（2004-06）的现有联系来估计因果关系。残余压力差分数将被用作多变量回归的结果变量，以评估癌症压力反应的程度以及与升高或持续反应相关的个体和情境特征。然后，这些差异分数将与癌症状况相互作用，以预测医疗保健利用（诊所/医院和预防保健）和健康结果。拟议的研究直接关系到NCI的使命，通过检查心理对癌症和癌症相关行为的影响，并通过启动一种工具的开发来识别高风险患者的持续升高的压力反应，从而改善癌症护理的提供和患者对癌症及其治疗的影响的适应。我们的调查结果将对医疗保健产生重要影响，允许针对风险最高的人群进行有效和高效的定制方案，从而提高患者的生活质量，同时减少昂贵的医疗保健使用。在诊断时确定有应激反应升高风险的老年癌症患者对于最大限度地提供高质量护理至关重要；然而，目前还没有一种临床工具来识别有高应激反应风险的老年患者。我们建议估计癌症诊断前后应激反应的性质、强度和持续时间，并确定与应激反应升高相关的个体和情境因素，同时评估其医疗保健利用和健康结果后果。我们的调查结果将对患者护理产生重要影响，包括减少患者痛苦和提高生活质量，同时减少过度的医疗保健利用及其相应的成本。

DESCRIPTION (provided by applicant): Advances in cancer detection and treatment have shifted cancer from a short-term, fatal disease, to a chronic condition necessitating a focus on longer-term outcomes. One-third to one-half of cancer patients experience lasting psychological distress (i.e. depression and anxiety). Distress predicts increased health care utilization at an excess annual cost of $2,000-3,000 per patient. Previous studies however, have severe methodologic limitations, including study designs limited to cancer patient follow-up, an emphasis on younger adult cancer survivors, and narrow stress definitions that do not incorporate a comprehensive stress assessment that includes measures of both positive and negative affect. The broader extent to which an adverse stress response is associated with health care utilization and health outcomes in the vulnerable older adult cancer patient population is unknown. Further, a clinical tool to help identify at-risk patients at the time of diagnosis does not exist. This is a critical limitation, as fewer than 10 percent of patients are actively referred for supportive services, suggesting that cancer-related stress is inadequately addressed in the clinic setting. The aims of this project are to: (1) assess the magnitude of increase in psychological stress symptoms pre- to post- cancer diagnosis; (2) determine whether patients at risk of a high or sustained stress response can be identified at the time of a cancer diagnosis; and (3) assess the effect that increased stress symptoms have on patient health care utilization and health outcomes. Data from the Wisconsin Longitudinal Study (WLS), a long- term study of a one-third random sample of men and women who graduated from Wisconsin high schools in 1957 and a randomly selected sibling (n=7,113), are used to accomplish these aims. Eleven percent of WLS respondents are cancer survivors. The analytic plan estimates causal effects by capitalizing on the WLS study design (longitudinal data, availability of a non-cancer control group, and paired sibling respondents) and existing linkages to the Wisconsin Tumor Registry (1979-2006) and Medicare databases (2004-06). Residualized stress difference scores will be used as an outcome variable in multivariate regressions to assess the magnitude of the cancer stress response and the individual and situational characteristics associated with an elevated or sustained response. These difference scores will then be interacted with cancer status to predict health care utilization (clinic/hospital and preventive care) and health outcomes. The proposed research directly relates to the NCI's mission by examining psychological influences on cancer and cancer-related behavior and by initiating development of a tool to identify at-risk patients of an elevated and sustained stress response, thereby improving cancer care delivery and patient adjustment to the effects of cancer and its treatment. The results from our investigation will have important implications for health care, allowing for the effective and efficient targeting of tailored programs to those at highest risk, thereby improving patient quality of life while reducing costly health care use. PUBLIC HEALTH RELEVANCE: Project Narrative Identifying older cancer patients at risk of an elevated stress response at the time of diagnosis is critical in order to maximize high quality care; however a clinical tool for identifying older patients at risk of a high stress response does not exist. We propose to estimate the nature, magnitude, and duration of the stress response pre- to post-cancer diagnosis and determine individual and situational factors associated with an elevated response, while simultaneously assessing its health care utilization and health outcome consequences. The results from our investigation will have important implications for patient care, including reducing patient suffering and improving quality of life while reducing excess health care utilization and its commensurate costs.