12月27日,，在線發(fā)表在J Clin Oncol雜志上的一則研究"Effect of Early Palliative Care on Chemotherapy Use and End-of-Life Care in Patients With Metastatic Non-Small-Cell Lung Cancer"表明早期姑息治療聯(lián)合標(biāo)準(zhǔn)治療可以幫助優(yōu)化最終化療和過渡到臨終關(guān)懷的選擇時間,?？偟膩碚f,，這會帶來高質(zhì)量的臨終護(hù)理,。
對于轉(zhuǎn)移性非小細(xì)胞肺癌,，接受早期姑息治療聯(lián)合標(biāo)準(zhǔn)抗癌方案的病人,，與那些只接受標(biāo)準(zhǔn)治療的病人相比,，去世前60天內(nèi)接受化療的幾率下降（OR,，0.47；95%CI,，0.23-0.99,；P=0.05）。前者使用最終劑量的靜脈化療到死亡的時間間隔更長（平均64天 vs. 50天,；P=0.02）,，納入超過1周的臨終關(guān)懷的人數(shù)更多（60.0% vs. 33.3%； P = 0.004）,。
這項(xiàng)研究是對去年發(fā)表在新英格蘭雜志上的一篇文章的隨訪（NEJM.2010;363:733-742）,，那篇研究表明早期姑息治療和標(biāo)準(zhǔn)治療的整合可以改善生存。在這篇后續(xù)的報(bào)道中,，作者指出,，化療的減少“對生存沒有損害，與傳統(tǒng)的觀點(diǎn)相反,，后者認(rèn)為更侵略性的治療可以延長轉(zhuǎn)移性癌癥的生命”,。
缺乏培訓(xùn)
最新的文章強(qiáng)調(diào)侵略性的治療不能延長轉(zhuǎn)移性實(shí)體瘤的生存期，姑息性治療不會縮短生存期,。即使之前已經(jīng)有報(bào)道說明支持性治療和侵略性化療是反向關(guān)系,，但早期的研究是觀察性的,，結(jié)果容易混淆影響。這篇研究采用隨機(jī)設(shè)計(jì),，更好的確認(rèn)了這種負(fù)相關(guān)關(guān)系,。以前的研究表明病人的治療方案中如果很少涉及臨終關(guān)懷，那么會更多的接受化療,。
以上表明一種可能性,，當(dāng)我們沒有臨終護(hù)理的支持，腫瘤科醫(yī)生傾向于做他們被培訓(xùn)要做的：給予化療,。
改善生存
這項(xiàng)研究的初步結(jié)果發(fā)表在2010年,，作者強(qiáng)調(diào)接受早期姑息治療同步進(jìn)行標(biāo)準(zhǔn)治療的病人生存期延長。該組中,，平均生存期是11.6個月,，對照組是8.9個月（p=0.02）,。2.7個月的受益于接受標(biāo)準(zhǔn)化療方案類似,。
提高轉(zhuǎn)移性NSCLC患者的生活質(zhì)量和情緒是一項(xiàng)艱巨的挑戰(zhàn)，這類人群通常隨著時間生活質(zhì)量會惡化,，在對照組就可以看到,。但是，接受早期姑息治療的病人的生活質(zhì)量確實(shí)在提高,。
減少靜脈化療
這項(xiàng)研究從2006年到2009年,，151名新診斷為轉(zhuǎn)移性NSCLC的病人被隨機(jī)分配到早期姑息治療聯(lián)合標(biāo)準(zhǔn)抗癌治療組，或者只有標(biāo)準(zhǔn)抗癌治療組,。最新的分析目的在于調(diào)查早期姑息治療是否也影響化療和臨終關(guān)懷治療的頻率和時間,。在18個月的隨訪中，大多數(shù)病人（n = 133; 88.1%）死亡,，作者評估了生命最后幾個月內(nèi)的化療率,。
作者發(fā)現(xiàn)，接受早期姑息治療聯(lián)合標(biāo)準(zhǔn)抗癌方案的病人,，與那些只接受標(biāo)準(zhǔn)治療的病人相比,，去世前60天內(nèi)接受化療的幾率下降（52.5% vs 70.1%； P = 0.05）,。隊(duì)列中,，59.7%的病人在最終方案中接受了靜脈化療，33.3%接受口服治療,，9個病人沒有接受化療,。早期姑息治療對降低靜脈治療有強(qiáng)大的影響，兩組間在死亡前60天內(nèi)有明顯差異（24.2% vs 46.3%,； P = 0.01）,。（生物谷Bioon.com）
doi:10.1200/JCO.2011.35.7996
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Effect of Early Palliative Care on Chemotherapy Use and End-of-Life Care in Patients With Metastatic Non-Small-Cell Lung Cancer.
Greer JA, Pirl WF, Jackson VA, Muzikansky A, Lennes IT, Heist RS, Gallagher ER, Temel JS.
PURPOSEPrior research shows that introducing palliative care soon after diagnosis for patients with metastatic non-small-cell lung cancer (NSCLC) is associated with improvements in quality of life, mood, and survival. We sought to investigate whether early palliative care also affects the frequency and timing of chemotherapy use and hospice care for these patients. PATIENTS AND METHODSThis secondary analysis is based on a randomized controlled trial of 151 patients with newly diagnosed metastatic NSCLC presenting to an outpatient clinic at a tertiary cancer center from June 2006 to July 2009. Participants received either early palliative care integrated with standard oncology care or standard oncology care alone. By 18-month follow-up, 133 participants (88.1%) had died. Outcome measures included: first, number and types of chemotherapy regimens, and second, frequency and timing of chemotherapy administration and hospice referral.ResultsThe overall number of chemotherapy regimens did not differ significantly by study group. However, compared with those in the standard care group, participants receiving early palliative care had half the odds of receiving chemotherapy within 60 days of death (odds ratio, 0.47; 95% CI, 0.23 to 0.99; P = .05), a longer interval between the last dose of intravenous chemotherapy and death (median, 64.00 days [range, 3 to 406 days] v 40.50 days [range, 6 to 287 days]; P = .02), and higher enrollment in hospice care for longer than 1 week (60.0% [36 of 60 patients] v 33.3% [21 of 63 patients]; P = .004). CONCLUSIONAlthough patients with metastatic NSCLC received similar numbers of chemotherapy regimens in the sample, early palliative care optimized the timing of final chemotherapy administration and transition to hospice services, key measures of quality end-of-life care.
