早期姑息疗法治疗转移性非小细胞肺癌患者
2011-06-07 Fatima Ajaz Richard MedSci原创
背景：转移性非小细胞肺癌患者的症状负荷明显，在临终前可能接受侵袭治疗。williamhill asia 研究了在新诊断的非卧床患者中引入早期姑息治疗对患者报告的结果和临终护理的影响。 方法：新诊断转移性非小细胞肺癌患者随机分配，接受早期姑息治疗结合标准肿瘤学护理或仅接受标准肿瘤护理。基线及12周时采用癌症治疗-肺功能量表（FACT-L）和医院焦虑和抑郁量表评估生活质量和情绪。主要终点是12周时生活质量的改变。从电子医疗记录收
背景：转移性非小细胞肺癌患者的症状负荷明显，在临终前可能接受侵袭治疗。williamhill asia
研究了在新诊断的非卧床患者中引入早期姑息治疗对患者报告的结果和临终护理的影响。
方法：新诊断转移性非小细胞肺癌患者随机分配，接受早期姑息治疗结合标准肿瘤学护理或仅接受标准肿瘤护理。基线及12周时采用癌症治疗-肺功能量表（FACT-L）和医院焦虑和抑郁量表评估生活质量和情绪。主要终点是12周时生活质量的改变。从电子医疗记录收集临终护理数据。
结果： 151名患者进行随机分组，12周时27名死亡，107名（余下患者的86％）完成评估。早期姑息治疗患者的生活质量优于仅接受标准护理患者（患者 FACT-L量表评分[评分范围0~136，数值越高表示生活质量越好]，98.0 vs 91.5，P=0.03）。此外，有抑郁症状的姑息治疗组患者少于接受标准治疗的患者（38％ vs 16％，P=0.01）。尽管早期姑息治疗组患者接受侵袭临终护理的比例低于标准治疗组患者（33％ vs 54％，P=0.05），但早期姑息治疗患者的中位生存期较长（11.6个月vs 8.9个月，P=0.02）。
结论：在转移性非小细胞肺癌患者，早期姑息治疗显著改善生活质量和情绪。与接受标准治疗的患者，早期姑息治疗的患者在临终阶段接受的侵袭治疗较少，但生存期较长。
BACKGROUND: Patients with metastatic non-small-cell lung cancer have a substantial symptom burden and may receive aggressive care at the end of life. We examined the effect of introducing palliative care early after diagnosis on patient-reported outcomes and end-of-life care among ambulatory patients with newly diagnosed disease.
METHODS: We randomly assigned patients with newly diagnosed metastatic non-small-cell lung cancer to receive either early palliative care integrated with standard oncologic care or standard oncologic care alone. Quality of life and mood were assessed at baseline and at 12 weeks with the use of the Functional Assessment of Cancer Therapy-Lung (FACT-L) scale and the Hospital Anxiety and Depression Scale, respectively. The primary outcome was the change in the quality of life at 12 weeks. Data on end-of-life care were collected from electronic medical records.
RESULTS: Of the 151 patients who underwent randomization, 27 died by 12 weeks and 107 (86% of the remaining patients) completed assessments. Patients assigned to early palliative care had a better quality of life than did patients assigned to standard care (mean score on the FACT-L scale [in which scores range from 0 to 136, with higher scores indicating better quality of life], 98.0 vs. 91.5; P=0.03). In addition, fewer patients in the palliative care group than in the standard care group had depressive symptoms (16% vs. 38%, P=0.01). Despite the fact that fewer patients in the early palliative care group than in the standard care group received aggressive end-of-life care (33% vs. 54%, P=0.05), median survival was longer among patients receiving early palliative care (11.6 months vs. 8.9 months, P=0.02).
CONCLUSIONS: Among patients with metastatic non-small-cell lung cancer, early palliative care led to significant improvements in both quality of life and mood. As compared with patients receiving standard care, patients receiving early palliative care had less aggressive care at the end of life but longer survival.
专家评论：
As intensivists and pulmonologists, we see a large number of patients with metastatic lung cancer requiring aggressive end-of-life care. The most important issues are decisions about end-of-life care, which are usually not addressed. Palliative care is considered to be an end-of-life intervention if no further treatment options are available. This article shows the benefits of using palliative care from the time of diagnosis of metastatic lung cancer. It shows that early palliative care along with standard oncologic treatment improves quality of life and mood. These patients received less aggressive end-of-life care and had a higher survival rate.
Evaluated by:Fatima Ajaz and Richard ZuWallack
At a time when anti-healthcare-reform politicians in the United States conjured up 'death panels' that would consign older patients to an early demise, this paper provides powerful evidence for the contrary. It also places the role of palliative and end-of-life care in cancer treatment into a new perspective. Given the obvious psychological benefit and possible medical benefit, palliative care including emotional support should be the standard of care in advanced cancer.专家评论：
As intensivists and pulmonologists, we see a large number of patients with metastatic lung cancer requiring aggressive end-of-life care. The most important issues are decisions about end-of-life care, which are usually not addressed. Palliative care is considered to be an end-of-life intervention if no further treatment options are available. This article shows the benefits of using palliative care from the time of diagnosis of metastatic lung cancer. It shows that early palliative care along with standard oncologic treatment improves quality of life and mood. These patients received less aggressive end-of-life care and had a higher survival rate.
Evaluated by:Fatima Ajaz and Richard ZuWallack
Evaluated by:David Spiegel
This study demonstrates the effect of palliative care on patients diagnosed with advanced lung cancer. Early integration of palliative care with standard oncologic care in patients with metastatic non-small-cell lung cancer resulted in prolonged survival and improved quality of life (QOL). It also resulted in greater documentation of resuscitation preferences in the outpatient electronic medical record as well as less aggressive care at the end-of-life.
Evaluated by:Pyng Lee
This landmark study showed that palliative care delivered as an adjuvant to (delivered along with) standard oncology care prolonged survival, decreased hospital utilization, and improved health-related quality of life (HRQoL) and mood for newly diagnosed patients with stage IV non-small-cell lung cancer (NSCLC). We all suspected it and now here are the data. This small study, and I do not mean to minimize the amount of labor that it took to accomplish this, provides the data to shake up the current paradigm of cancer care. This study is an important, technically competent proof of principle which should be taken as a challenge to the prevailing, and probably mistaken, belief that palliative care is the same as hospice care.Evaluated by:Miriam Rodin
专家评价：
1，作为一个重症监护和胸肺科医生，williamhill asia
看到大多数需要侵袭临终护理的转移性肺癌患者。最重要的问题是制定临终护理决策，这通常没有充分研究。姑息治疗被认为是在没有进一步治疗方案可选择的情况下进行的临终干预。本文介绍从转移性肺癌诊断时采用姑息疗法的获益。研究显示，早期姑息疗法联合标准肿瘤学护理可改善生活质量和情绪。这些患者接受的侵袭性临终关怀较少，存活率较高。作者发现，初诊非小细胞癌患者接受早期姑息治疗可改善生活质量和情绪。这些患者接受的临终护理侵袭性较小，生存期更长。作者将151名新诊断转移性非小细胞肺癌患者随机分组，接受早期姑息治疗联合标准肿瘤学护理或仅接受标准肿瘤学护理。姑息性治疗组平均存活期较长（11.6个月vs 8.9个月P=0.02）。试验注册：NCT01038271
作者：atima Ajaz and Richard ZuWallack
2，美国反对卫生保健改革的政治家认为'死亡小组'将任由老年患者早日死亡，在这一时代背景之下，本文提供了有力的反驳证据。同时还从一个新的角度阐明了姑息治疗和临终护理在癌症治疗中的作用。由于能使患者获得明显的心理获益及可能的医疗获益，姑息疗法包括情感支持应该是中晚期癌症的标准护理。
作者进行了一项随机临床试验，151例非小细胞肺癌患者分为早期姑息治疗干预组，平均接受4次访视，重点研究复苏方式的选择、疼痛控制和生活质量。其他患者接受标准癌症治疗。 “尽管接受的临终护理侵袭性小，但姑息治疗组患者比接受标准治疗患者的生存期显著延长（中位生存期，11.65个月 vs 8.9个月，P=0.02）”（p. 738）。生活质量更好。这项研究表明，在临终阶段，最积极的治疗可能不是最有效的。研究还表明，帮助患者面对死亡并对护理水平做出知情同意，注意控制疼痛和痛苦不仅是人道的，而且较强化抗癌治疗更为有效。williamhill asia
的研究小组在1989年发表的一项随机研究表明，每周接受支持性表达集体心理治疗的转移性乳腺癌女性的存活期（平均18个月）明显长于接受标准治疗的患者{1}。在最近的研究中，williamhill asia
发现干预没有任何整体效果，但与雌激素受体（ER）的状态存在显著相互作用，干预组ER阴性肿瘤患者存活更久{2}。ER阴性乳腺癌患者没有从抗雌激素治疗{3}相关的预后改善中受益。其他一些研究未能证实这一发现 {4}，但另一些研究证实了这一发现{5}。没有研究表明重视情绪和死亡率缩短了存活（见文献{6}，我是该文作者）。本研究证实了临终期支持性干预的医学获益。试验注册：NCT01038271
作者：David Spiegel
3. 本研究证实了姑息疗法治疗晚期肺癌患者的疗效。尽早将姑息治疗纳入转移性非小细胞肺癌患者的标准肿瘤护理可延长存活并改善生活质量（QOL）。其门诊电子病历中有更多关于复苏选择的记录，临终时接受的侵袭性护理较少。
新诊断的转移性非小细胞肺癌患者随机分配接受包含有早期姑息治疗的标准肿瘤护理或仅接受标准肿瘤护理。在基线和12周时对生活质量和情绪进行评估。共招募151例，12周时27例死亡，107例（86％）完成评估。早期姑息治疗组患者较标准肿瘤护理患者的生活质量更好（FACT-L评分 98.0 vs 91.5，P=0.03）。姑息治疗组有抑郁症状和接受侵袭性临终监护的比例较低。早期姑息治疗患者的中位生存期也较长（11.6个月vs8.9个月，P=0.02）。鉴于临终监护趋向于侵袭性和高成本，适时引入姑息治疗可能减少不必要的个人和社会成本。如需阅读背景内容，请参阅文献{1-3}。试验注册：NCT01038271
作者：Pyng Lee
4.这一里程碑式文章证实在诊断晚期非小细胞肺癌（NSCLC）不久后接受包含早期姑息疗法的标准肿瘤学实践可能提高生活质量、情绪和整体生存。若经确认，这一研究结果将支持对转移性非小细胞肺癌和生存期短、症状严重的其他肿瘤患者的护理模式进行转变。这项研究将促使研究者就将早期姑息治疗作为晚期肺癌标准护理这一问题进行讨论。对于资源配置和提高肿瘤科医生的姑息疗法培训也具有重要意义。
在这项研究中，151例新诊断的晚期非小细胞肺癌患者（东部肿瘤协作组 [ECOG]评分0-2）以非盲法随机方式随机分为标准肿瘤护理或包含有早期姑息疗法的多学科综合治疗组。干预包括在入组3周内接受姑息治疗团队访视，此后至少每月一次在门诊接受访视直至死亡。如果患者或医生要求，对照组患者可以接受姑息治疗。该研究的主要终点是12周时生活质量较基线时的变化，以癌症治疗肺功能（FACT）评估量表进行测定。次要结果为抑郁、健康服务的利用包括抗肿瘤治疗、药物治疗、入住临终关怀医院、住院、急诊和整体生存。如果符合以下任何条件：死亡前14天之内接受化疗、未接受临终服务或入住临终关怀医院3天或以内死亡，则认为患者接受了“侵袭性临终护理”。所有分析均为意向治疗。研究结果证实了预期的结果：早期姑息治疗的患者其生活质量改善，抑郁症状减少（16％vs 38％）。姑息性治疗组的患者较少接受“侵袭性临终护理”（33％vs 54％）。最有趣的是，接受早期姑息治疗患者的中位总生存期明显延长（11.6个月vs 8.9个月，p = 0.02）。改善整体存活率的假设原因包括由于症状控制改善、最大限度减少无意义“侵袭性临终护理”的毒性使抑郁减少、住院减少所致的间接获益。这项研究表明，早期姑息治疗可改善症状和生活质量，同时对整体存活率有正面影响。生存幅度的改变与转移性肺癌治疗方式改变的临床试验相似。这项研究的优势包括随机设计和研究包括生存在内的多个相关预后。本研究的局限是基于单一的机构，得到其他研究单位的验证方可推广。此外，非盲设计和缺乏注意控制可能影响结果，尤其是自我评估报告。然而，这些结果可促进肿瘤科医生考虑将早期姑息治疗作为标准肿瘤治疗的组成部分，对于大多数老年患者的预后具有改善。
作者：Miriam Rodin
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本网站所有内容来源注明为“williamhill asia 医学”或“MedSci原创”的文字、图片和音视频资料，版权均属于williamhill asia 医学所有。非经授权，任何媒体、网站或个人不得转载，授权转载时须注明来源为“williamhill asia 医学”。其它来源的文章系转载文章，或“williamhill asia 号”自媒体发布的文章，仅系出于传递更多信息之目的，本站仅负责审核内容合规，其内容不代表本站立场，本站不负责内容的准确性和版权。如果存在侵权、或不希望被转载的媒体或个人可与williamhill asia 联系，williamhill asia 将立即进行删除处理。
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#肺癌患者#
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#姑息疗法#
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#非小细胞#
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#转移性#
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#转移性非小细胞肺癌#
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#非小细胞肺癌患者#
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#姑息#
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