Variation in Provider Breast Cancer Surveillance Strategies Following Initial Treatment: Contribution of Patient and Provider Factors, Association with Outcomes, and Stakeholder Insights

项目摘要/摘要 对于在最初治疗阶段幸存下来的300万乳腺癌患者来说，常规 监测复发并不能改善结果。尽管通过成像或血液测试， 在癌症出现症状或体征之前发现复发，大型随机对照试验和Cochrane 数据库系统审查发现，这种监测在生存或质量方面没有任何好处 乳腺癌患者的生活质量。如果检测是不必要的，就会给患者带来不必要的风险 包括辐射暴露、患者焦虑和可能导致不必要检查的假阳性 这本身就有风险。 尽管有证据和指导方针建议不要这样做，但有证据表明，监视测试经常 发生在乳腺癌的初步治疗之后。最近的单一机构和团体模型HMO研究和 一项更早的全国性研究发现，约有一半的早期患者使用了先进的成像技术 乳腺癌。关于利用血液检测肿瘤标志物进行监测的信息很少。 我们的长期目标是更好地了解司机对监控测试的使用及其 对结果的影响，并确定潜在的干预措施，以引导提供者和患者的行为得到改善 结果和降低成本(财务和辐射风险)。一旦监控测试的重要驱动因素使用 这些信息至少可以通过三种方式用来提高护理价值。首先，患者会 更好地了解与以下方面相关的潜在风险--成本和辐射暴露 监视测试。其次，由于美国每年在成像和其他与疾病相关的测试上花费超过40亿美元 癌症护理，即使稍微减少昂贵的不必要的监测测试的使用也会 在不增加死亡率的情况下，节省了大量资金。第三，如果供应商了解影响，或者 缺乏对患者结果的现代监测测试方法，包括经济负担， 辐射风险和死亡率，他们遵守指南的意愿，以及患者的预后，都可能得到改善。 在这个项目中，我们将在全国范围内对监督检测使用的变化进行估计，并将 生成关于提供者特征和实践模式之间的关联的第一数据，以及 监督检测率(目标1和3)。我们将提供有关监测对患者影响的第一批数据 和社会结果，第一次估计了由于这样做的检测而造成的成本和辐射暴露 不符合准则(目标2和4)。最后，我们将创建第一个定性数据，使我们能够 产生关于为什么会发生监测的假设，这些假设可以用来制定干预措施，以减少 可以在未来的随机试验中测试的不必要的测试。

PROJECT SUMMARY/ABSTRACT For the 3 million patients with breast cancer who have survived the initial treatment phase, routine surveillance for recurrence does not improve outcomes. Although it is possible, using imaging or blood tests, to find cancer recurrence before it produces symptoms or signs, large randomized controlled trials and Cochrane database systematic reviews have found that such surveillance offers no benefit in terms of survival or quality of life for patients with breast cancer. Testing, if unwarranted, involves unnecessary risks to the patient including radiation exposure, patient anxiety, and potential false positives resulting in unnecessary work-up that carries its own risks. Despite the evidence and guidelines advising against it, there is evidence that surveillance testing often occurs after initial treatment of breast cancer. Recent single institution and group model HMO studies and an older national study found evidence of that advanced imaging is used in about half of patients with early stage breast cancers. There is little information about surveillance using blood tests for tumor markers. Our long-term goal is to develop an improved understanding of drivers of surveillance test use and its impact on outcomes and to identify potential interventions to steer provider and patient behavior to improved outcomes and reduced cost (financial and radiation risk). Once the significant drivers of surveillance test use are identified, this information can be used to improve value of care in at least three ways. First, patients will have a better understanding of the potential risks—in terms of cost and radiation exposure—associated with surveillance testing. Second, since the US spends over $4 billion per year on imaging and other tests related to cancer care, even a small reduction in the utilization of expensive unnecessary surveillance tests would represent significant financial savings without increasing mortality. Third, if providers understand the effect, or lack of effect, of modern methods of surveillance testing on patient outcomes, including financial burden, radiation risk, and mortality, their willingness to adhere to guidelines, and patient outcomes, could improve. In this project we will create estimates of the variation in surveillance testing use nationally, and will generate the first data regarding the association between provider characteristics and practice patterns and surveillance testing rates (Aims 1 and 3). We will provide the first data on the impact of surveillance on patient and societal outcomes, for the first time estimating the costs of and radiation exposure due to testing done that is not consistent with guidelines (Aim 2 and 4). Finally, we will create the first qualitative data to allow us to generate hypotheses about why surveillance occurs, which could be used to develop interventions to reduce unnecessary testing that can be tested in future randomized trials.