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：大肠癌（CRC）是美国癌症死亡的第二大原因。筛选减少 发生率和死亡率，部分是由于检测和去除息肉（例如腺瘤）。指南 去除腺瘤后，建议的监视结肠镜检查（“多型切除术”），但 息肉切除术后降低CRC风险的监测尚不确定。对于75岁及以上的成年人（“老年人”） 考虑监测结肠镜检查，这些问题尤其重要。与之相关的危害 随着年龄的增长，结肠镜检查急剧增加。老年人的寿命不足以从中受益。 诸如竞争非CRC死亡率风险造成的监视结肠镜检查之类的干预措施。福 与年龄相关的建立竞争导致死亡率和与结肠镜检查有关的危害的风险增加的风险 与主要证据差距形成鲜明对比；目前尚不清楚CRC风险在临床上是否具有临床意义 具有先前息肉历史的老年人，以及暴露老年人监测是否会降低CRC风险。 然而，默认的临床范例是许多老年人接受监视结肠镜检查。意义：in 退伍军人事务部（VA），监视是结肠镜检查的非常普遍的迹象 年长的退伍军人，估计每年受到17,400次暴露于监视。可用的不匹配 证据和当前的临床实践，再加上对VA结肠镜检查资源的极端限制 使监视结肠镜检查范式成为量化风险和收益的理想重点领域 优化健康结果。创新与影响：在先前的老年人中建立CRC风险 与监视相关的多型切除术和结果将填补关键的证据差距。多利益相关者 关于CRC风险和监视结果的观点将为未来实施证据铺平道路 - 基于老年人监视的基于以资深人士为中心的和优化的价值策略。这项工作也将 充当利用VA数据来应对VA大型人口健康挑战的模型 并增加了老年人的人口以及如何使用这些数据吸引退伍军人以优化结果。 具体目的：目标1）比较75岁以后的累积CRC风险 正常结肠镜检查（n = 101,328）与结肠镜检查，息肉切除术（n = 29,548）。假设：假设： 事件CRC的累积风险（主要分析）和致命CRC（二次分析）在75岁之后将是 在75岁之前进行结肠镜检查与结肠镜检查正常的结肠镜检查的老年人相似。 目标2）评估暴露的比较有效性与没有暴露于降低CRC风险的监视。 假设：老年人暴露与暴露于监视的情况将有类似的事件CRC风险（主要 分析）和致命的CRC（二级分析）。目标3）获得有关多层次利益相关者的观点 CRC风险和监视结果，以告知有关监视结肠镜检查的未来使用和VA政策 年长的退伍军人。方法：AIM 1将利用先前建立的结肠镜检查队列进行比较 患有正常结肠镜检查与多型切除术的老年人中CRC的风险。 AIM 2将采用案件 - 队列设计以评估与先前多型切除术的老年人中CRC（病例）的风险 暴露于监测结肠镜检查的意外。 AIM 3将包括对患者的一对一采访 和提供者（AIM 3A）并召集了由多个利益相关者（包括患者，提供者， 和VA策略制定者）审查目标1、2和3A的数据，并为监视提出建议 老年人的结肠镜检查可以指导老年人监视的VA政策。下一步/ 实施：VA内外的准则将由有关CRC风险的新颖证据告知 具有先前息肉切除术的老年人以及暴露于监视对CRC风险预后的影响，以及 多方利益相关者对新证据应如何为决策和临床实践提供的观点。