Chemotherapy Near Death: Modifiable Factors and Outcomes in Ovarian Cancer

濒临死亡的化疗：卵巢癌的可改变因素和结果

• 批准号: 8508591
• 负责人: Alexi A Wright
• 金额: $ 17.71万
• 依托单位: DANA-FARBER CANCER INST
• 依托单位国家: 美国
• 财政年份: 2013
• 资助国家: 美国
• 起止时间: 2013-08-05 至 2018-07-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8508591
• 关键词: Advanced Malignant Neoplasm; American Society of Clinical Oncology; Atlases; Behavior; Cancer Patient; Caregivers; Caring; Cessation of life; Cognitive; Dana-Farber Cancer Institute; Data; Data Analyses; Data Sources; Decision Making; Distress; Emotional; Environmental air flow; General Hospitals; Goals; Health; Health system; Healthcare; Influentials; Intervention; Intervention Studies; Life; Link; Malignant Neoplasms; Malignant neoplasm of gastrointestinal tract; Malignant neoplasm of lung; Malignant neoplasm of ovary; Massachusetts; Medical; Medicare; Mentors; Morbidity - disease rate; Oncologist; Outcome; Patient Care; Patient Preferences; Patients; Physicians; Platinum; Provider; Psychosocial Factor; Quality of life; Recurrence; Regimen; Research; Research Personnel; Resistance; Resuscitation; Survey Methodology; Surveys; Terminal Disease; Terminally Ill; Testing; Therapeutic; Training; Uncertainty; base; chemotherapy; cohort; coping; cost; end of life; evidence base; experience; health care service utilization; hospice environment; improved; medical supply; novel; older patient; population based; preference; prognostic; prospective; skills; therapy design

DESCRIPTION (provided by applicant): The use of chemotherapy at the end-of-life (EOL) is increasing, despite growing concerns that it may be burdensome, expensive, and potentially harmful. Between 20-50% of terminally-ill cancer patients receive chemotherapy in the last month of life (henceforth referred to as EOL chemotherapy). Rates are highest in ovarian cancer where patients may respond to multiple lines of chemotherapy, increasing uncertainty about when to stop treatment. Research suggests that EOL chemotherapy is associated with more aggressive EOL care and lower rates of hospice utilization, both of which are associated with worse patient quality of life (QoL) near death, higher costs, and more distress in bereaved caregivers. Recently, the American Society of Clinical Oncology (ASCO) identified EOL chemotherapy first on its "Top Five List" of widely used practices that could improve patient care while reducing costs, if stopped. The determinants of EOL chemotherapy use are poorly understood. Researchers from the Dartmouth Health Care Atlas have argued that cancer patients' EOL care is determined by medical supply factors, not patient preferences. In contrast, we have found that patients' treatment preferences, providers' behaviors, and the therapeutic alliance between patients and oncologists predict the intensity of advanced cancer patients' EOL care, both adjusting for and stratifying by health systems. Most recently, we have found that late-line chemotherapy is one of the most powerful predictors of aggressive EOL care in patients with advanced lung and gastrointestinal cancers. In Coping with Cancer, patients who received late-line chemotherapy, a median of 4.5 months before death, had 8-fold higher odds of undergoing ventilation or resuscitation in the last week of life, compared with patients who did not. These preliminary results highlight the need to determine outcomes of late-line chemotherapy in other cancers, to understand better what factors influence the receipt of EOL chemotherapy, and to develop an intervention to improve EOL care. The overall goals of this project are: a) to examine outcomes of late-line chemotherapy (defined as e2 non- platinum-based regimens) in patients with platinum-resistant ovarian cancer, including whether patients are receiving care that is congruent with their preferences (treatment goal attainment), b) to identify modifiable determinants of EOL chemotherapy use to target in an intervention, and c) to develop an intervention to decrease EOL chemotherapy use. Two complementary data sources will be used for Aims 1&2: 1) a prospective, longitudinal, multi-institutional study of 200 patient with recurrent, platinum-resistant ovarian cancer (Coping with Cancer 2~ CwC2)~ and 2) a population-based cohort of 10,310 older patients with advanced ovarian cancer from SEER-Medicare. In Aim 1, I will use CwC2 data to examine associations between late-line chemotherapy and patient QoL, intensity of EOL care, and goal attainment~ and SEER-Medicare to examine patients' EOL health care utilization and patients' cancer and/or treatment related morbidity. In Aim 2, I will use CwC2's comprehensive information on psychosocial factors to examine modifiable patient and caregiver factors associated with EOL chemotherapy use, paired with a new physician survey which I will develop, refine, test, implement, and link to CwC2 data to identify modifiable physician factors associated with EOL chemotherapy. In Aim 3, I will develop and pilot an intervention at the Dana-Farber Cancer Institute and Massachusetts General Hospital to decrease EOL chemotherapy use, based upon my findings in Aims 1 and 2, which will likely target physicians since they are the most influential determinants of decisions to forgo life-sustaining treatments in other contexts.39 Together, these data will provide an evidence base to improve chemotherapy decision-making, identify novel and modifiable determinants of EOL chemotherapy, and allow me to target the these determinants in an intervention designed to decrease EOL chemotherapy use. The portfolio of proposed analyses, combined with close mentoring and specific training in decision-making, longitudinal data analysis, survey methodology, and intervention research, will equip me with the necessary skills and experience to transition from a mentored research fellow to become a successful, independent researcher.

描述（由申请人提供）：尽管人们越来越担心它可能是繁重的，昂贵的且可能有害的，但在生命终止（EOL）的化学疗法的使用却在增加。在20％至50％的终末癌症患者中，在生命的最后一个月接受化学疗法（此后称为EOL化学疗法）。在卵巢癌中，患者可能会对多种化学疗法做出反应，这增加了何时停止治疗的不确定性。研究表明，EOL化学疗法与更具侵略性的EOL护理和较低的临终关怀使用率有关，这两者都与近期死亡，较高的成本和丧亲护理人员的困扰相关的患者生活质量（QOL）较差。最近，美国临床肿瘤学会（ASCO）首先在其广泛使用的实践的“前五名”中确定了EOL化学疗法，这些实践可以改善患者护理，同时降低成本（如果停止）。 EOL化学疗法使用的决定因素知之甚少。达特茅斯医疗保健地图集的研究人员认为，癌症患者的EOL护理是由医疗供应因素而不是患者偏好决定的。相比之下，我们发现患者的治疗偏好，提供者的行为以及患者和肿瘤学家之间的治疗联盟预测晚期癌症患者的EOL护理的强度，包括卫生系统调整和分层。最近，我们发现晚期化学疗法是晚期肺和胃肠道癌患者的侵略性EOL护理最强大的预测指标之一。在应对癌症时，接受后期化疗的患者（死亡前4.5个月的中位数）在生命的最后一周进行通风或复苏的几率高出8倍 不是。这些初步结果强调了确定其他癌症晚期化疗的结果的必要性，以更好地了解哪些因素会影响哪些因素影响EOL化学疗法的接收，并开发一种干预措施以改善EOL护理。 The overall goals of this project are: a) to examine outcomes of late-line chemotherapy (defined as e2 non- platinum-based regimens) in patients with platinum-resistant ovarian cancer, including whether patients are receiving care that is congruent with their preferences (treatment goal attainment), b) to identify modifiable determinants of EOL chemotherapy use to target in an intervention, and c) to develop an intervention to decrease EOL chemotherapy 使用。 目标1和2：1）对200例复发性，耐铂耐药性卵巢癌患者（与癌症的2〜CWC2）〜和2）进行了前瞻性，纵向，多机构研究（2〜CWC2）〜和2），这是一个基于人群的10,310例10,310例老年卵巢癌患者的同类。在AIM 1中，我将使用CWC2数据来检查晚期化疗与患者QOL，EOL护理强度以及目标实现和SEER-MEDICARE之间的关联，以检查患者的EOL医疗保健利用率和患者的癌症和/或与治疗相关的发病率。在AIM 2中，我将使用CWC2关于心理社会因素的综合信息来检查与EOL化学疗法使用相关的可修改患者和护理人员因素，并与我将开发，完善，测试，实施和链接到CWC2数据的新医师调查，以识别与EOL化学疗法相关的可修改医生。在AIM 3中，根据我在目标1和2中的发现，我将在Dana-Farber癌症研究所和马萨诸塞州综合医院开发干预措施，以减少EOL化学疗法的使用，这可能是针对医生的，因为它们可能是针对性的，因为它们是最具影响力的决定性的决定因素，可以在其他情况下放弃生命疗法，以在其他情况下提供良好的验证。化学疗法，并让我在旨在减少EOL化学疗法使用的干预措施中靶向这些决定因素。拟议分析的组合，结合了决策，纵向数据分析，调查方法和干预研究的仔细指导和特定培训，将使我拥有从指导的研究人员过渡到成功，独立的独立研究人员的必要技能和经验。