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

项目总结/摘要 对于300万在初始治疗阶段存活下来的乳腺癌患者， 监测复发并不能改善预后。虽然有可能，使用成像或血液测试， 在出现症状或体征之前发现癌症复发，大型随机对照试验和科克伦 数据库系统评价发现，这种监测在生存率或质量方面没有益处 乳腺癌患者的生活。如果没有必要，检测会给患者带来不必要的风险 包括辐射暴露、患者焦虑和导致不必要检查的潜在假阳性 有其自身的风险。 尽管有证据和指导方针反对它，但有证据表明，监督检测往往 发生在乳腺癌的初始治疗后。最近的单一机构和团体模式HMO研究和 一项较早的国家研究发现，有证据表明，大约一半的早期癌症患者使用了先进的成像技术。 乳腺癌关于使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监督测试的使用及其 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， 结果和降低成本（财务和辐射风险）。一旦监控测试使用的重要驱动因素 这些信息可以至少在三个方面用于提高护理的价值。首先，患者将 更好地了解与以下因素相关的潜在风险-在成本和辐射风险方面 监督测试其次，由于美国每年花费超过40亿美元用于成像和其他相关测试， 癌症护理，即使少量减少昂贵的不必要的监测测试的使用， 这意味着在不增加死亡率的情况下节省了大量资金。第三，如果供应商了解效果，或 缺乏对患者结果进行监测测试的现代方法，包括经济负担， 辐射风险和死亡率，他们遵守指南的意愿，以及患者的结果，都可以改善。 在这个项目中，我们将建立全国监测测试使用变化的估计，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 监测检测率（目标1和3）。我们将提供关于监测对患者影响的第一批数据 和社会后果，第一次估计的成本和辐射暴露，由于测试完成， 不符合准则（目标2和4）。最后，我们将创建第一个定性数据， 提出关于监测发生原因的假设，这些假设可用于制定干预措施， 不必要的测试，可以在未来的随机试验中进行测试。

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.