Involving older adults in decision making for skin cancer

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PROJECT SUMMARY/ABSTRACT .. Although over 3.6 million basal and squamous cell carcinoma (collectively termed non-melanoma skin cancer or NMSC) and almost 40 million pre-cursor lesions (actinic keratosis) are treated in the US each year, these skin lesions are not dangerous. I have argued that for many frail, older adults at the end of life, the risks of treatment of these highly prevalent tumors may often outweigh the benefits, making nonsurgical management, including active surveillance, a reasonable management option. As these are ubiquitous, slow- growing tumors, patients should be informed of the risks and benefits of all management options in order to make choices consistent with their clinical characteristics, values, and preferences. My goal in applying for a Beeson Emerging Leaders Career Development Award is to gain the knowledge and skills necessary to address the needs of older dermatologic patients with a new outlook informed by geriatrics. I recognize that the science of aging requires a unique skill set, and I cannot be successful in this new field without specific training and mentorship in geriatrics. To accomplish my goals, I need a deeper understanding of geriatric research principles and clinical geriatrics as well as new research skills in qualitative research, patient recruitment, primary data collection, and development and testing of decision tools. Together with my mentoring team, I have developed a rigorous training program that includes outstanding mentoring, structured tutorials, didactic coursework, and presentations at local and national conferences. This training plan will enable me to apply core principles of geriatric science and shared decision- making to the field of dermatology, which will ultimately improve individualized patient-centered dermatology care for older adults. My central hypothesis is that older adults who are fully informed and engaged in management decisions will likely choose more conservative treatment options, report fewer complications, higher satisfaction, and better quality of life. In preparation for testing this hypothesis, I propose to determine the extent of actinic keratosis procedure use near the end of life, using a national database of older adults (Aim 1). By conducting in-depth interviews and focus groups with patients, caregivers, and physicians, I will learn about patients' knowledge and preferences about NMSC and actinic keratoses treatment and barriers to shared decision-making. (Aim 2). This work will result in a set of evidence-based and patient-driven decision tools that can be used in clinical practice (Aim 3). Accomplishing these aims will provide the preliminary data needed to develop a competitive R01 application to test my central hypothesis by determining how these decision tools impact treatment utilization and patient-reported outcomes in a randomized, controlled trial of patients with limited life expectancy.