Improving shared decision-making around the use of disease modifying anti-rheumatic drugs in patients with rheumatoid arthritis and cancer

项目总结 超过180万美国人患有类风湿性关节炎(RA)。与一般人口相比，这些人 患者患癌症的风险增加，特别是淋巴瘤和肺癌。已经有了 一种理论关注，即使用免疫抑制剂可能会削弱对肿瘤放置的免疫反应 有可能罹患新癌症和以前治疗过的癌症复发的患者。这些担忧 使临床医生不愿对活动期或最近诊断为RA的患者使用标准疗法 癌症。虽然只有有限数量的研究评估了它们的安全性，但它们实际上并没有显示出任何 类风湿性关节炎和癌症患者服用抗风湿药物(DMARDS)的危害信号。 然而，这些研究有许多局限性，包括主要集中在偏远地区(&gt；5年)的患者。 癌症病史，样本量小，只关注某些DMARD，和/或关于癌症的有限信息- 具体的死亡率和其他可能对患者有影响的结果。此外，人们对 正在接受癌症治疗的类风湿关节炎患者的观点和经历，以及这种经历是如何 可能会影响他们使用DMARDS的意愿。类风湿关节炎治疗指南支持a 共享决策(SDM)方法，试图利用 风湿科医生坚持对每个患者最重要的东西。在此，我们提出了一种混合方法 找出加强对这些患者的护理的最佳方式，并提供基础 共享决策，以确保治疗决策与价值观、目标和 患者个人的喜好。 这里提出的研究将建立一个证据基础，以确定患者最安全的DMARD选择 与患癌症的类风湿性关节炎患者(目标1)；获得以下方面的经验、看法和最有价值的结果 活动期或最近诊断为癌症(5年)的类风湿性关节炎患者及其家人和临床医生 谁照顾这些病人(目标2)。 这项由K23指导的职业发展提案的总体目标是支持纳姆拉塔·辛格博士 作为一名独立的、以患者为导向的研究人员，其长期目标是开发一项研究 议程的重点是确定造成次优治疗的因素和结果 风湿病患者，尤其是癌症患者。这里提出的培训和研究计划 将使她在高级药物流行病学和定性研究方法方面发展关键技能。 再加上一支优秀的导师团队，华盛顿大学的世界级设施和 严格的培训计划，这个项目将为辛格博士成功获得未来的资金进行适应和测试做好准备 对类风湿关节炎患者和活动期或近期癌症患者实施SDM的决策辅助。

PROJECT SUMMARY Over 1.8 million Americans have rheumatoid arthritis (RA). Compared to the general population these patients are at an increased risk of developing cancer, especially lymphoma and lung cancer. There has been a theoretical concern that use of immunosuppressive agents may impair immune responses to tumors placing patients at risk for developing new cancers and for recurrence of previously treated cancers. These concerns have made clinicians reluctant to use standard therapies for RA in patients with an active or recently diagnosed cancer. Although only a limited number of studies have evaluated their safety, they have in fact not shown any signal of harm from disease modifying anti-rheumatic drugs (DMARDs) in patients with RA and cancer. However, these studies have numerous limitations including focus on mostly patients with remote (> 5 years) history of cancer, small sample sizes, focus on only certain DMARDs, and/or limited information on cancer- specific mortality and other outcomes that might matter to patients. Also, nothing is known about the perspectives and experiences of patients with RA who are being treated for a cancer and how this experience might shape their willingness to use DMARDs. Treatment guidelines for the management of RA support a shared decision-making (SDM) approach that attempts to leverage the professional expertise of the rheumatologist to uphold what is most important to each patient. We herein propose a mixed methods approach to identify the optimal ways to enhance delivery of care for these patients and to provide a foundation for shared decision making to ensure alignment between treatment decisions and the values, goals, and preferences of individual patients. The studies proposed here will build an evidence base to identify the safest DMARD options for patients with RA who develop cancer (Aim 1); elicit the experiences, perceptions, and most valued outcomes of patients with RA and an active or recently diagnosed (<5 years) cancer, their family members and clinicians who care for these patients (Aim 2). The overall goal of this K23 mentored career development proposal is to support Dr. Namrata Singh’s development as an independent, patient-oriented researcher whose long-term goal is to develop a research agenda focused on the identification of factors that contribute to suboptimal treatment and outcomes for patients with rheumatic diseases, especially those with cancer. The training and research plans proposed here will allow her to develop critical skills in advanced pharmacoepidemiology and in qualitative research methods. Combined with an outstanding mentorship team, the University of Washington’s world-class facilities, and a rigorous training plan, this project will prepare Dr. Singh to successfully obtain future funding to adapt and test a decision aid for SDM implementation among patients with RA and an active or recent cancer.