Tailored Screening for Urinary System Cancers in Patients with Chronic Kidney Disease

项目摘要 慢性肾脏病(CKD)是一种高度流行的疾病，在50岁和50岁以下的人中发现20% 年纪更大了。虽然众所周知，慢性肾脏病与心血管死亡率密切相关，但最近的研究表明 显示了与癌症风险的关联，这也值得考虑预防策略。癌症是 慢性肾脏病早期中年患者的主要死因和第二大死因 在所有65岁以下的慢性肾脏病患者中。具体地说，肾癌的发病率是患者的三倍 患有CKD，包括患有中度CKD(15-60岁)的年轻男性(40-52岁)的风险比高达3.4 Ml/min/1.73m2)。事实上，慢性肾脏病中年患者的肾癌发病率与老年人相似。 结直肠癌在普通人群中的发病率。慢性肾脏病患膀胱癌的风险也同样增加。当前 指南建议CKD患者接受常见肾脏和心血管危险因素的监测 这与吸烟、高血压和肥胖症等尿道癌的发病率有重叠。因此，缺乏 明确的癌症筛查建议是CKD实践指南中的一个重要缺口，可能是 由于对健康状况各不相同的人群的利益和危害进行了复杂的权衡。 我们的专家团队在决策科学、流行病学、泌尿外科肿瘤学、肾脏病学、放射学和 内科将应用补充经验来评估筛查策略的潜力。我们 之前开发并发布了肾脏肿瘤和合并症的计算机模拟模型， 在NCI K奖的支持下，肾脏解剖和肾肿块的功能(再肯定)模拟 模特。我们的模型能够模拟由CKD严重程度和肾脏定义的亚群的结果 肿瘤自然病史。我们将改变模型，将膀胱癌的自然病史以及 肾脏和膀胱的筛查途径。我们将评估癌症筛查途径是否有益于生命 预期寿命和质量-基于年龄、慢性肾脏病分期、强烈共存的危险因素调整的预期寿命，以及 共病负担。没有其他明显心血管合并症和多发性心血管疾病的中年人 已确定的危险因素可能需要进行更密集的筛查，而心血管疾病患者 而且，很少有风险因素可以保证不那么密集的筛查。此外，患有慢性肾脏病的黑人男性和女性 反复被证明与非黑人CKD相比，全因和癌症特异性死亡率更高 患者，这是形成筛查建议时的一个重要考虑因素。我们的调查结果将由 一个由初级保健、肾病、泌尿外科和患者权益倡导领域的独立利益相关者组成的小组考虑 模型结果支持的筛查的可接受性和障碍。成本效益也将是 探索影响或提高筛查价值的关键因素。我们的目标将是在 哪些尿路筛查建议可以使大量CKD人群受益。

Project Summary Chronic kidney disease (CKD) is a highly prevalent condition, found in 20% of people aged 50 years and older. While it is well known that CKD is strongly associated with cardiovascular mortality, recent work has demonstrated an association with cancer risk that also merits consideration for preventive strategies. Cancer is the leading cause of death in mid-life patients afflicted by early stages of CKD, and the 2nd leading cause across all CKD patients under 65 years. Specifically, kidney cancers occur three times more often in patients with CKD, including a hazard ratio of up to 3.4 in younger men (40-52 years) with moderate CKD (15-60 mL/min/1.73 m2). Indeed, the incidence of kidney cancer in mid-life patients with CKD is similar to that of colorectal cancer in the general population. Risks of bladder cancer are similarly increased in CKD. Current guidelines recommend that CKD patients undergo monitoring of common renal and cardiovascular risk factors that overlap with those of urinary tract cancers such as smoking, hypertension, and obesity. Thus, the lack of clear cancer screening recommendations represents an important gap in CKD practice guidelines, and may be due to the complex weighing of benefits and harms for a population with wide-ranging health status. Our team of experts in decision science, epidemiology, urologic oncology, nephrology, radiology, and internal medicine will apply complementary experience to assess the potential of screening strategies. We previously developed and published a computer simulation model of kidney tumors and comorbidities, supported by an NCI K award, the Renal Anatomy and Function for Renal Masses (Re-AFFiRM) simulation model. Our model is capable of simulating outcomes of subpopulations defined by CKD severity and kidney tumor natural history. We will transform the model to incorporate bladder cancer natural history as well as kidney and bladder screening pathways. We will assess whether cancer screening pathways benefit life expectancy and quality-adjusted life expectancy based on age, CKD stage, strong co-existing risk factors, and comorbidity burden. Middle-aged adults without other significant cardiovascular comorbidity and multiple established risk factors may warrant more intensive screening, whereas patients with cardiovascular disease and few risk factors may warrant less intensive screening. In addition, Black men and women with CKD have been shown repeatedly to suffer higher all-cause and cancer-specific mortality compared to non-Black CKD patients, an important consideration in forming screening recommendations. Our findings will be evaluated by a group of independent stakeholders in primary care, nephrology, urology, and patient advocacy to consider the acceptability and barriers to screening as supported by the model results. Cost-effectiveness will also be explored for key factors that affect or elevate the value of screening. Our goal will be to establish the context in which urinary tract screening recommendations could benefit the large population with CKD.