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Behavioral Economics and Improving Chemotherapy Decisions for Advanced Cancer

Nancy L Keating

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National Institutes of Health (NIH)
In 2012, more than 1.6 million Americans were diagnosed with cancer and about 577,000 died of cancer. Evidence, including work that I have conducted, suggests that many patients with cancer do not receive the care that is recommended by guidelines, and such deficiencies are associated with worse outcomes. Evidence also suggests that many patients do not receive care that is concordant with their preferences, particularly for patients with advanced cancers. This application for a NCI K24 Midcareer Investigator Award in Patient Oriented Research seeks support to provide Dr. Keating with necessary protected time to further develop her capabilities and expertise in cancer-related patient oriented research and to expand her ability to mentoring promising junior investigators in patient-oriented research. Dr. Keating's prior research has focused on: (1) understanding patient, provider, and organizational factors influencing the care delivered to patients with cancer and (2) understanding outcomes for cancer patients in non-trial settings. Much of this work has identified challenges in the receipt of high-quality care. Her research has resulted in more than 120 peer-reviewed original research articles in top general medicine and oncology journals. She has a strong and successful record of independent research funding from the National Cancer Institute and foundations, including the American Cancer Society, the Prostate Cancer Foundation, and the Komen for the Cure Foundation. The high quality of her research has been recognized by her induction into the American Society for Clinical Investigation, an honor society recognizing individuals with an outstanding record of scholarly achievement in biomedical research before the age of 45. Dr. Keating's immediate career goals and objectives are to acquire skills in behavioral economics, decision science, and intervention research to identify and test promising opportunities to improve care for patients with cancer, to further her work in understanding the reasons for sub-optimal care delivered to cancer patients, and to continue to provide outstanding mentorship and attract new investigators to mentor in the conduct of rigorous patient-oriented research focused on improving cancer care and outcomes. The K24 award will be instrumental in achieving these objectives. Dr. Keating's career development plan involves formal coursework, seminars, targeted readings, and mentored research. She will study behavioral economics and decision science theory and their applications to health care, and particularly patients' decisions about treatment for cancer. She will also develop skills in intervention research. She will work closely throughout the duration ofthe award with a group of highly skilled clinician researchers and scientists, including Drs. Michael Norton, Kevin Volpp, Peter Ubel, Eric Winer, and Anthony Back. Dr. Keating works in a rich environment with ready access to talented collaborators and trainees and support staff. She has demonstrated a commitment to mentoring young investigators in patient-oriented research, with 26 senior author publications since 2012, and increasing successes among her prior mentees. She has access to trainees from across the Harvard community, including students, residents, post-doctoral fellows, and junior faculty, and she has a variety of ongoing projects that provide excellent opportunities for mentoring junior investigators in patient-oriented research in oncology. Dr. Keating's research project seeks to apply behavioral economic and decision science principles to improve patients' understanding of the goals of chemotherapy for advanced cancer by updating and broadening the default information that patients receive in the chemotherapy consent form. Evidence from the fields of behavioral economics and decision science suggests that individuals do not always make rational decisions that might bring the best outcomes for them. Individuals are typically overly optimistic, are biased towards rewards in the present vs. the future, are susceptible to the way that information is framed, have a tendency to select default options, and are regret averse. Other research has shown that most patients with metastatic cancer do not understand the goals of chemotherapy. A revised consent form can serve as a "nudge" to physicians to provide patients with information about the goals of chemotherapy. It also gives patients written information about goals of chemotherapy to take home with them. Better information should make patients better informed about the goals of chemotherapy and may ultimately decrease the use of later lines of chemotherapy, where benefits are likely to be smaller. Dr. Keating's project has two aims. First, she and her mentees will revise the chemotherapy consent form based on focus groups with patients and physicians. The revised consent form will include information about the purpose of chemotherapy and information about the likely duration of life extension when life extension is a goal. Second, they will assess whether the use of this consent form can increase patients' understanding of the goals of chemotherapy and prognostic understanding and decrease use of late-line chemotherapy for advanced cancer.

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