Locoregional Treatment Decision-making in Older Adults with Early-Stage, Hormone Receptor-Positive Breast Cancer

项目摘要/摘要 在美国，70年来每年有超过83,000例新的乳腺癌病例被诊断出来，其中大多数 女性患有早期激素受体阳性(HR+)疾病。对这些女性的过度治疗是一个日益令人担忧的问题， 现有数据表明，强度较低的局部区域治疗(即降级治疗)总体上不会减少 生死存亡。众所周知，与保乳手术(BCS)相比，乳房切除并不能带来生存优势， 新出现的试验数据也支持安全省略放射治疗(RT)和腋窝淋巴结评估。 继续进行放疗和腋窝淋巴结评估会增加手术部位感染、出血、 慢性疼痛、淋巴水肿和辐射诱发的恶性肿瘤。然而，省略这些治疗可能与 局部区域复发率略有增加。因此，这些妇女面临着复杂的治疗决定，这可能是 由于存在老年人特有的问题，如虚弱、预期寿命、功能状态和 相互竞争的风险。尽管肿瘤学专业协会支持将老年病的特殊关注纳入治疗 在决策方面，尚不清楚医生在多大程度上听取了这一建议。 共享决策(SDM)强化了患者自主的重要性，可以促进高质量 决策(定义为与患者价值观一致的明智决策)，有助于减少 过度治疗。然而，SDM也可能是一个困难和耗时的过程，而现有的数据持有的数据很少 医生一直试图让患者参与决策，更少的医生根据患者的关切和 偏好。考虑到患有早期HR+乳腺癌的老年人面临的决策困难，有一个 迫切需要了解如何在这一人群中改进SDM。 此GEMSSTAR应用程序寻求对旨在了解特定于老年人的初步工作的支持 在人群一级和病人-医生一级都将关切问题纳入治疗决策。 交谈。我的研究目的是：1)确定与医生水平和地区差异相关的因素 使用SEER-Medicare对患有早期HR+乳腺癌的老年人进行降级局部区域治疗 数据，以及2)详细说明老年人的具体问题(例如，虚弱、预期寿命、功能状态和竞争风险) 目前集成到治疗对话中，并通过使用话语创建患者-医生交互类型 分析老年早期、HR+乳腺癌患者的音频临床接触情况 外科、内科和放射肿瘤学家。完成这些目标将为未来的研究奠定坚实的基础 探索有效的SDM中患者和医生因素的复杂相互作用，并针对以下目标进行有针对性的干预 调节医患相互作用以提高早期乳腺癌老年妇女的决策质量。 这项工作反过来将减少过度治疗并改善患者护理。此外，这个奖项将为我提供 我需要支持、指导、培训和网络，才能成为学习和提高 老年乳腺癌患者的治疗决策、临床结果和肿瘤学结果。

Project Summary/Abstract Over 83,000 new breast cancer cases are diagnosed annually in the U.S in women >70 years, and most of these women have early-stage, hormone receptor-positive (HR+) disease. Overtreatment of these women is a growing concern, as existing data demonstrate that less-intense locoregional therapy (i.e. de-escalated therapy) does not decrease overall survival. It is well-established that mastectomy does not confer a survival benefit over breast-conserving surgery (BCS), and emerging trial data also support safe omission of radiation therapy (RT) and axillary lymph node evaluation. Proceeding with RT and axillary lymph node evaluation comes with an increased risk of surgical site infection, bleeding, chronic pain, lymphedema, and radiation-induced malignancy. Omitting these treatments, however, may be associated with a small increase in locoregional recurrence. These women thus face complex treatment decisions, which can be further complicated by the presence of geriatric-specific concerns, such as frailty, life expectancy, functional status, and competing risks. Though oncologic professional societies endorse integration of geriatric-specific concerns into treatment decision-making, it is unclear to what extent physicians heed this recommendation. Shared decision making (SDM) reinforces the importance of patient autonomy, can facilitate high-quality decisions (defined as knowledgeable decisions that are concordant with patient values), and can help to reduce overtreatment. SDM, however, can also be a difficult and time-consuming process, and existing data hold that few physicians consistently attempt to involve patients in decision making, and even fewer adjust care to patient concerns and preferences. Given the observed decisional difficulty faced by older adults with early-stage HR+ breast cancer, there is a critical need to understand how SDM can be improved in this population. This GEMSSTAR application seeks support for preliminary work aimed at understanding how geriatric-specific concerns are integrated into treatment decision-making, both on a population-level and at the level of patient-physician conversations. My research aims are to: 1) determine factors associated with physician-level and regional variation in the receipt of de-escalated locoregional treatment of older adults with early-stage HR+ breast cancer using SEER-Medicare data, and 2) detail how geriatric-specific concerns (e.g. frailty, life expectancy, functional status, and competing risks) are currently integrated into treatment conversations and to create patient-physician interaction typologies by using discourse analysis to analyze audio-recorded clinical encounters between older adults with early-stage, HR+ breast cancer and surgical, medical, and radiation oncologists. Completion of these aims will set a strong foundation for future studies exploring the complex interplay of patient and physician factors in effective SDM and for targeted interventions aimed at modulating patient-physician interactions to improve decisional quality for older women with early stage breast cancer. This work will, in turn, reduce overtreatment and improve patient care. In addition, this award would provide me with the support, mentorship, training, and networking I need to become a national leader in the study and improvement of treatment decision-making, clinical outcomes, and oncologic outcomes, in older adults with breast cancer.