|
|
晚期癌症患者大多需要家庭照顾者的支持。家庭照顾者平均每天要提供8小时的照顾，其心理压力不小于癌症患者本人。姑息治疗开始的时间太晚会更增加家庭照顾者的压力。
The ENABLE III randomized controlled trial of concurrent palliative oncology care.
ENABLEⅢ：此项研究为家庭照顾者提供干预性帮助措施。针对晚期癌症患者该研究观察了诊断后立即与延迟3个月之后开始同步姑息性肿瘤治疗对患者生存及生活质量的影响。研究中应用的干预性措施包括姑息治疗咨询，患者记录;姑息治疗知识宣教;自我治疗与症状管理;沟通及治疗计划;生命回顾;原谅;写遗嘱等。
结果显示，诊断后立即接受姑息治疗的患者较延迟姑息治疗者1年死亡风险降低28%[风险比(HR)=0.72，95%可信区间(CI)为0.57~0.89，P=0.003)。
立即姑息治疗组的家庭照顾者的生活质量、抑郁、压力负荷方面有改善，提示肿瘤姑息治疗应越早越好，以最大程度地为照料者带来获益。
Citation:J Clin Oncol 32:5s, 2014 (suppl; abstr 9512)
Author(s):
Marie Bakitas, Tor Tosteson, Zhigang Li, Kathleen Lyons, Jay Hull, Zhongze Li, J Nicholas Dionne-Odom, Jennifer Frost, Mark Hegel, Andres Azuero, Tim Ahles, James R. Rigas, J. Marc Pipas, Konstantin H. Dragnev; The University of Alabama at Birmingham Comprehensive Cancer Center, Birmingham, AL; Norris Cotton Cancer Center, Lebanon, NH; The Geisel School of Medicine at Dartmouth, Hanover, NH; Dartmouth College, Hanover, NH; Memorial Sloan-Kettering Cancer Center, New York, NY; Dartmouth Medical School, Hanover, NH; Dartmouth Hitchcock Medical Center, Lebanon, NH; Dartmouth-Hitchcock Medical Center, Lebanon, NH
Abstract:
Background: Evidence from randomized controlled trials (RCTs) supports integration of oncology and palliative care; how soon after diagnosis to initiate palliative care has not been defined. Methods: We conducted a ‘fast track’ RCT of patients with advanced cancer in a rural, NCI-designated cancer center, VAMC, and community clinics in NH and VT to determine the effect of immediate vs. delayed (3 months after diagnosis) entry patients into the ENABLE concurrent oncology palliative care intervention on primary outcome measures: QOL (FACIT-pal), symptom impact (Symptom impact subscale of the QUAL-E, mood (CES-D), at 3 and 6 months and survival at 1 year (from enrollment to death or study completion). Other outcomes included: resource use (hospital and ICU days and ER visits-measured by chart review), and quality of EOL care. Results: Participants (immediate n=104; delayed=103) were mean age 65; 52% male; 65% married; 96% white; 42% lung; 46% newly diagnosed with advanced disease; 17% with brain metastases. The estimated treatment effects (TE) using a terminal decline model (Cohen’s d; immediate minus delayed) for patients from randomization to 3 months were: (mean [SE]: .13 (21.39) for QOL (P=.34), -.21 (3.63) for symptom impact (P=.09), and .04 (3.91) for depressed mood (P=.33). 104 participants died (immediate n=49; delayed n=55) during the study. Compared to delayed entry patients, the risk of death (hazard ratio [HR] (95% CI)) was lower for immediate participants at 1 year 0.72 (95% CI, 0.57-0.89) (P=0.003). Median survival for immediate entry patients was 18.3 months (95% CI, 13.2, 28.0) and 11.8 months (95% CI, 9.0, 24.1) for delayed entry patients (P=0.17). Overall median hospital days (3), ICU days (0), and ER visits (1) were identical. 55% (27) of 49 deaths in immediate and 49% (27) of delayed deaths occurred at home. Conclusions: Immediate vs delayed entry patients experienced a significant survival advantage at 1 year; however longitudinal TE were not statistically different. Future research is needed to define mechanisms of survival advantage in palliative care trials. Clinical trial information: NCT01245621.
|
|
