Surveillance Colonoscopy in Older Adults: The SurvOlderAdults Study

老年人结肠镜检查监测：SurvOlderAdults 研究

• 批准号: 10638065
• 负责人: Samir Gupta
• 金额: --
• 依托单位: VA SAN DIEGO HEALTHCARE SYSTEM
• 依托单位国家: 美国
• 财政年份: 2023
• 资助国家: 美国
• 起止时间: 2023-10-01 至 2027-09-30
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10638065
• 关键词: Address; Adult; Age; Area; Benefits and Risks; Cancer Etiology; Caring; Cessation of life; Clinical; Colonoscopy; Colorectal Cancer; Coupled; Data; Decision Making; Deimplementation; Detection; Diagnosis; Elderly; Emergency Situation; Excision; Exposure to; Future; Gastroenterologist; Geriatrics; Goals; Guidelines; Health; Health Personnel; Hospitalization; Incidence; Intervention; Interview; Knowledge; Malignant Neoplasms; Methodology; Modeling; Outcome; Patients; Policies; Policy Maker; Polypectomy; Polyps; Population; Primary Care; Provider; Recommendation; Recording of previous events; Research; Resources; Risk; Risk Reduction; Sampling; Structure; United States; United States Department of Veterans Affairs; United States Preventative Services Task Force; Veterans; Visit; Work; adenoma; age related; clinical practice; clinically significant; cohort; colon growth; colorectal cancer risk; colorectal cancer screening; comparative effectiveness; design; evidence base; experience; future implementation; health goals; high risk; innovation; mortality; mortality risk; novel; population health; primary outcome; screening; secondary analysis; stakeholder perspectives; surveillance strategy; young adult

Background: Colorectal cancer (CRC) is the 2nd leading cause of cancer death in the US. Screening reduces incidence and mortality, in part due to detection and removal of polyps such as adenomas. Guidelines recommend surveillance colonoscopy after adenoma removal (“polypectomy”), but incremental benefit of surveillance after polypectomy on reducing CRC risk is uncertain. For adults age 75 and older (“older adults”) considering surveillance colonoscopy, these issues are of particular importance. Harms associated with colonoscopy increase dramatically with age. Older adults are less likely to live long enough to benefit from interventions such as surveillance colonoscopy due to competing non-CRC mortality risks. The well- established age-related increasing risks for competing causes of mortality and colonoscopy-related harms stand in sharp contrast to major evidence gaps; it is unclear whether CRC risk is clinically significant among older adults with prior history of polyps, and whether exposing older adults to surveillance reduces CRC risk. Yet, the default clinical paradigm is for many older adults to receive surveillance colonoscopy. Significance: In the Department of Veterans Affairs (VA), surveillance is a very common indication for colonoscopy among older Veterans, with an estimated 17,400 exposed to surveillance annually. The mismatch between available evidence and current clinical practice, coupled with extreme constraints on colonoscopy resources in the VA make the surveillance colonoscopy paradigm an ideal focus area for quantifying risks and benefits in order to optimize health outcomes. Innovation & Impact: Establishing CRC risk among older adults with prior polypectomy and outcomes associated with surveillance will fill critical evidence gaps. Multi-stakeholder perspectives on CRC risk and surveillance outcomes will pave the way for future implementation of evidence- based, Veteran-centric, and optimized-value strategies for surveillance among older adults. This work will also serve as a model for leveraging VA data to address an important population health challenge for the VA’s large and growing older adult population and how to use these data to engage Veterans to optimize outcomes. Specific Aims: Aim 1) Compare cumulative CRC risk after age 75 in a cohort of older adults with history of normal colonoscopy (n=101,328) vs. colonoscopy with polypectomy (n=29,548) prior to age 75. Hypothesis: Cumulative risk for incident CRC (primary analysis) and fatal CRC (secondary analysis) after age 75 will be similar among older adults who had normal colonoscopy vs. colonoscopy with polypectomy prior to age 75. Aim 2) Assess comparative effectiveness of exposure vs. no exposure to surveillance for reducing CRC risk. Hypothesis: Older adults unexposed vs. exposed to surveillance will have similar risk for incident CRC (primary analysis) and fatal CRC (secondary analysis). Aim 3) Obtain multi-level stakeholder perspectives regarding CRC risk and surveillance outcomes to inform future use and VA policy regarding surveillance colonoscopy in older Veterans. Methodology: Aim 1 will leverage a previously established colonoscopy cohort to compare risk for CRC among older adults with prior normal colonoscopy vs. polypectomy. Aim 2 will employ a case- cohort design to evaluate risk for CRC (cases) among older adults with prior polypectomy subsequently exposed vs. unexposed to surveillance colonoscopy. Aim 3 will include one-on-one interviews with patients and providers (Aim 3a) and convening an expert panel of multiple stakeholders (including patients, providers, and VA policymakers) to review data from Aims 1, 2, and 3a and generate recommendations for surveillance colonoscopy in older adults that can guide VA policy around surveillance among older adults. Next Steps/ Implementation: Guidelines within and outside VA will be informed by the novel evidence on CRC risk among older adults with prior polypectomy and impact of exposure to surveillance on CRC risk outcomes, as well as multi-stakeholder perspectives on how new evidence should inform decision-making and clinical practice.

背景：结直肠癌 (CRC) 是美国第二大癌症死亡原因。 发病率和死亡率，部分归因于腺瘤等息肉的检测和切除。 建议在腺瘤切除（“息肉切除术”）后进行监测结肠镜检查，但 对于 75 岁及以上的成年人（“老年人”），息肉切除术后的监测是否可以降低 CRC 风险尚不确定。 考虑到监视结肠镜检查，这些问题尤其重要。 随着年龄的增长，结肠镜检查的数量急剧增加，而老年人的寿命不太可能从结肠镜检查中受益。 由于竞争性非结直肠癌死亡风险而采取的干预措施，例如监测结肠镜检查。 已确定与年龄相关的死亡竞争原因和结肠镜检查相关危害的风险不断增加 与主要证据差距形成鲜明对比；目前尚不清楚结直肠癌风险是否具有临床意义 有息肉病史的老年人，以及让老年人接受监测是否会降低结直肠癌风险。 然而，许多老年人的默认临床模式是接受监测结肠镜检查。 退伍军人事务部 (VA) 表示，监测是结肠镜检查的一个非常常见的指征 每年估计有 17,400 名老年退伍军人受到监视。 证据和当前的临床实践，加上退伍军人管理局结肠镜检查资源的极端限制 使监测结肠镜检查范式成为量化风险和收益的理想重点领域，以便 优化健康结果：确定既往病史的老年人的 CRC 风险。 息肉切除术和与监测相关的结果将填补多方利益相关者的关键证据空白。 对 CRC 风险和监测结果的看法将为未来实施证据铺平道路 这项工作还将针对老年人进行基于退伍军人的、优化价值的监测策略。 充当利用 VA 数据解决 VA 大型人口健康挑战的模型 不断增长的老年人口，以及如何利用这些数据让退伍军人参与优化结果。 具体目标： 目标 1) 比较具有以下病史的老年人队列中 75 岁后的累积 CRC 风险： 75 岁之前的正常结肠镜检查 (n=101,328) 与结肠镜检查加息肉切除术 (n=29,548)。 假设： 75 岁后发生 CRC 事件（初步分析）和致命 CRC（二次分析）的累积风险将为 在 75 岁之前接受过正常结肠镜检查的老年人与接受息肉切除术的结肠镜检查的老年人中相似。 目标 2) 评估暴露与不暴露监测对于降低 CRC 风险的比较有效性。 假设：未接触过监测的老年人与接触过监测的老年人发生 CRC 的风险相似（原发性 分析）和致命 CRC（二次分析） 目标 3) 获得多层次利益相关者的观点。 CRC 风险和监测结果可为未来使用和 VA 关于监测结肠镜检查的政策提供信息 方法论：目标 1 将利用先前建立的结肠镜检查队列进行比较。 既往进行过正常结肠镜检查与息肉切除术的老年人患 CRC 的风险比较，目标 2 将采用案例 - 队列设计评估随后接受过息肉切除术的老年人患结直肠癌（病例）的风险 目标 3 将包括与患者进行一对一访谈。 和提供者（目标 3a），并召集多个利益相关者（包括患者、提供者、 和 VA 政策制定者）​​审查目标 1、2 和 3a 的数据并生成监测建议 老年人结肠镜检查可以指导 VA 围绕老年人监测的政策。 实施：VA 内部和外部的指南将根据有关 CRC 风险的新证据提供信息 既往接受过息肉切除术的老年人以及暴露于监测对 CRC 风险结果的影响，以及 多利益相关者关于新证据应如何为决策和临床实践提供信息的观点。