头颈部肿瘤放疗相关口腔黏膜炎的流行病学调查及诊疗现状研究

发布时间：2018-03-14 18:26

本文选题：头颈部肿瘤　切入点：放射治疗　出处：《华中科技大学》2014年博士论文　论文类型：学位论文

【摘要】：目的放射治疗是头颈部肿瘤最主要的治疗方法之一。然而,尽管放疗技术不断在进步,口腔黏膜炎(Oral Mucositis, OM)仍是头颈部肿瘤放疗过程中最常见的毒副反应之一。OM常引起不同程度的口腔及咽部疼痛,严重者需要阿片类药物镇痛,同时常影响患者进食,引起营养摄入障碍,严重影响患者生活质量,甚至影响治疗计划顺利进行,并增加住院日及治疗花费。尽管OM对患者生活质量及治疗均造成了极大影响,其在临床工作中却很少得到足够且正确的预防及治疗。本研究旨在：1)调查OM在头颈部肿瘤放疗患者中的发病率、影响因素及导致的结果；2)研究放疗相关OM的临床诊疗现状；3)调查肿瘤内科医师对OM诊疗知识的知晓及态度。方法 1.以2013年11月至2014年1月同济医院肿瘤放疗中心头颈部放疗患者为研究对象,收集患者一般信息(性别、年龄、身高、体重、诊断、诱导化疗情况等),以美国国家癌症研究所(National Cancer Institute, NCI)常见不良反应分级标准(Common Terminology Criteria for Adverse Events, CTCAE)每周对患者OM情况、白细胞计数、中性粒细胞计数等进行评估,直至治疗结束,并记录患者同步化疗情况及治疗结束后体重变化。 2.调查以上患者口腔黏膜炎诊断情况,并以2013年癌症支持治疗多国协会／国际口腔肿瘤协会(MASCC/ISOO)抗肿瘤治疗相关OM临床实践指南为基础,对患者接受的OM相关治疗进行调查,了解其诊疗现状。 3.设计调查问卷,调查肿瘤内科医师对放疗相关OM流行病学、诊断分级标准、诊疗方法及诊疗指南的知晓情况,分析临床医师对放疗相关OM的认识及态度。结果 1.流行病学调查结果： (1)共纳入头颈部肿瘤患者101名,93.1%的患者出现OM,严重OM(3级及以上)为66.3%。严重OM的危险因素包括,患者相关因素：原发肿瘤位于鼻咽部(OR=3.7,95%CI1.6～8.9)及放疗过程中出现白细胞减少(OR=5.3,95%CI2.1-13.3)；治疗相关因素：接受了诱导化疗(OR=5.7,95%CI1.6～20.1)、同步化疗(OR=5.4,95%CI2.2～13.3)及放疗累积剂量超过70Gy(OR=18.4,95%CI2.4～143.2)。 (2)OM持续时间平均为(5.0±1.4)w。严重OM平均持续(3.3+0.8)w。原发肿瘤位于鼻咽部(5.4±1.8w vs.4.5±1.9w, P=0.002)及接受了同步化疗(5.3+0.8wvs.4.4±2.0w,P=0.001)的患者OM持续时间较长。 (3)放疗后患者体重下降平均为(4.0±2.7)kg,50.5%患者接受了肠外营养支持,33.7%的患者需要住院治疗,平均住院时间为(10.2.±6.9)天。严重OM患者体重下降更多(5.0±2.5kg vs.1.7±1.7kg,P=0.000),且肠内营养应用(OR=7.4,95%CI2.8～19.5)、阿片类药物使用(OR=7.3,95%CI1.6～33.4)及住院风险(OR=14.6,95%CI3.2～66.0)更高。 2.头颈部放疗相关OM的诊疗现状： (1)43.6%的患者病历中有OM相关的诊断或记录。进行了明确诊断的患者仅占11.7%,仅3名(3.2%)患者OM诊断中包含了分级。 (2)用于预防/治疗OM的措施繁多,其中仅7.7%患者接受了预防OM的措施,全部为基础口腔护理。使用率最高的5项措施包括：静脉注射抗细菌药物(73.3%)、基础口腔护理(52.5%)、静脉注射地塞米松(46.5%)、雾化吸入(46.5%)及利多卡因漱口(35.6%)。 (3)严重OM患者使用抗细菌药物(OR=14.5,95%CI4.9～42.8)的风险更高。 3.临床医师对头颈部放疗相关OM的认识及态度： (1)50%医师认同头颈部放疗相关OM发病率超过80%,近一半(48.3%)医师认为其对患者产生了较大影响。但仅58.6%的医师认为自己对OM的诊治足够重视。 (2)仅20.7%的医师会定期对患者进行口腔检查(至少1次／周)。参与调查医师最常用的OM分级标准为WHO标准(50.0%)。十分了解或完全了解OM诊断分级标准的医师仅占14.3%。 (3)常规对头颈部放疗患者进行OM预防的医师占31.0%。医师认为有效的预防／治疗措施前5位包括：基础口腔护理(94.7%)、局部麻醉药物(利多卡因等)(78.9%)、地塞米松(78.9%)、营养支持(78.9%)、粒(巨噬细胞)-集落刺激因子(G(M)-CSF)(68.4%)。无效措施前5位包括：蜂蜜(36.8%)、洗必泰漱口水(21.1%)、苄达明漱口水(21.1%)、硫糖铝漱口水(15.8%)、低剂量激光疗法(15.8%)。 (4)对于MASCC/ISOO癌症相关OM指南,41.4%的医师不了解。大部分(62.1%)的医师认为在管理头颈部放疗相关OM方面接受的培训不足。结论 1.头颈部放疗相关OM发病率高,几乎不可避免。原发肿瘤位于鼻咽部、接受了诱导化疗、同步化疗、放疗累积剂量超过70Gy及放疗过程中出现白细胞减少与OM的严重程度相关。OM与患者体重下降、肠内营养应用、阿片类药物使用及住院率增加相关。 2.目前临床实践中对于头颈部放疗相关OM的诊疗尚不规范,漏诊率高。治疗OM的药物种类繁多,但多为经验性用药,对现有循证医学证据的实施度不足。 3.问卷调查显示医师对OM缺乏重视。对相关理论知识,包括诊疗指南的知晓度低,造成医师对OM预防及治疗的认识存在很大误区。突出了对肿瘤科医师进行OM相关诊疗知识培训的必要性。
[Abstract]:objective
Radiotherapy is one of the main methods of treatment of head and neck cancer. However, despite advances in radiotherapy of oral mucositis (Oral, Mucositis, OM) is still the most common adverse reaction of radiotherapy for head and neck cancer in the process of.OM is often caused by oral and pharyngeal pain in different degree, serious need for opioid analgesia at the same time, often affect patients caused by eating, nutrition disorder, seriously affect the life quality of patients, and even affect the treatment plan, and increased hospitalization and treatment costs. Although OM on quality of life of patients and treatment were made into a great influence in the clinical work has rarely been enough and correct prevention and treatment. The purpose of this study is to investigate: 1) the incidence of OM in patients with head and neck cancer radiotherapy rate, influencing factors and results; 2) clinical research status of radiotherapy of OM; 3) the investigation of tumor The knowledge and attitude of the physician on the knowledge of OM diagnosis and treatment.
Method
From November 2013 to January 2014 1. to Tongji Hospital cancer radiotherapy center head and neck radiotherapy patients as the research object, collecting general information (gender, age, height, weight, diagnosis, chemotherapy, etc.) to the National Cancer Institute (National Cancer, Institute, NCI) common adverse reactions (Common Terminology Criteria for standard Adverse Events CTCAE), weekly for patients with OM, white blood cell count, neutrophil count evaluation, until the end of treatment, and record the weight change of patients with synchronous chemotherapy and after treatment.
2., we investigated the diagnosis of oral mucositis in the above patients. Based on the OM clinical practice guideline of cancer support therapy of the Multinational Association / International Association of oral cancer (MASCC/ISOO) in 2013, we investigated the OM related treatment of patients and found its diagnosis and treatment.
3., design a questionnaire to investigate the awareness of radiotherapy related OM epidemiology, diagnostic grading criteria, diagnosis and treatment guidelines, and analyze the clinicians' perceptions and attitudes towards radiotherapy related OM.
Result
1. the results of epidemiological survey:
(1) a total of 101 patients with head and neck cancer, 93.1% patients with OM and severe OM (grade 3 and above) for severe OM 66.3%. including risk factors, related factors of patients with primary tumor in the nasopharynx (OR=3.7,95%CI1.6 ~ 8.9) and radiotherapy leukopenia (OR=5.3,95%CI2.1-13.3) treatment; factors: received induction chemotherapy (OR=5.7,95%CI1.6 ~ 20.1), chemotherapy (OR=5.4,95%CI2.2 ~ 13.3) and cumulative doses of radiotherapy more than 70Gy (OR=18.4,95%CI2.4 ~ 143.2).
(2) the average duration of OM was (5 + 1.4) W., and severe OM lasted for an average of (3.3+0.8) w.. The primary tumor located in the nasopharynx (5.4 + 1.8W vs.4.5 + 1.9W, P=0.002) and the patients who received concurrent chemotherapy (5.3+0.8wvs.4.4 + 2.0W, P=0.002) lasted longer.
(3) after radiotherapy for patients with weight loss on average (4 + 2.7) kg, 50.5% patients received parenteral nutrition, 33.7% patients required hospitalization, the average hospitalization time (10.2. + 6.9) days. Body weight decreased more in patients with severe OM (5 + 2.5kg vs.1.7 + 1.7kg, P=0.000), and intestinal application of nutrition (OR=7.4,95%CI2.8 ~ 19.5), the use of opioids (OR=7.3,95%CI1.6 ~ 33.4) and the risk of hospitalization (OR=14.6,95%CI3.2 ~ 66) higher.
2. the status of diagnosis and treatment of OM related to radiotherapy in the head and neck:
(1) 43.6% of the patients had a OM related diagnosis or record. Only 11.7% of the patients were diagnosed, and only 3 (3.2%) had a classification in the OM diagnosis.
(2) for the prevention / treatment of OM range, which only 7.7% of the patients received OM prevention measures, all based on oral care. Including the use of the highest rate of 5 measures: intravenous injection of anti bacteria drugs (73.3%), (52.5%), oral care based intravenous injection of dexamethasone (46.5%), atomization inhalation of lidocaine gargle (46.5%) and (35.6%).
(3) the risk of using anti bacterial drugs (OR=14.5,95%CI4.9 ~ 42.8) in severe OM patients is higher.
3. cognition and attitude of clinicians to head and neck radiotherapy related OM:
(1) 50% physicians agree that the incidence of OM related to head and neck radiotherapy is more than 80%, nearly half (48.3%) of doctors believe that it has a great impact on patients. However, only 58.6% of doctors think they pay enough attention to the diagnosis and treatment of OM.
(2) only 20.7% of the physicians regularly perform oral examination on their patients (at least 1 times / week). The most commonly used OM grading standard is WHO standard (50%). Physicians who know or understand OM diagnostic grading standards only account for 14.3%..
(3) conventional radiotherapy in patients with head and neck OM prevention physicians accounted for 31.0%. physicians believe that prevention / treatment is effective measures before the 5 include: basic oral care (94.7%), local anesthetic (lidocaine and dexamethasone) (78.9%), (78.9%), nutritional support (78.9%), grain (macrophage colony -) stimulating factor (G (M) -CSF) (68.4%). 5 effective measures include: (36.8%) honey, chlorhexidine mouthwash slobber (21.1%), (21.1%) benzydamine mouthwash slobber, sucralfate mouthwash slobber (15.8%), low dose laser therapy (15.8%).
(4) 41.4% of physicians do not know about OM guidelines for cancer related MASCC/ISOO. Most (62.1%) of doctors believe that there is insufficient training in management of head and neck radiotherapy related OM.
conclusion
1. head and neck radiotherapy related to the incidence of OM is high, almost inevitable. The primary tumor in the nasopharynx, received induction chemotherapy, chemotherapy, radiotherapy and cumulative dose more than 70Gy in the process of radiotherapy leukopenia weight related to severity of.OM and patients with OM decreased, the application of enteral nutrition, opioid use and the hospitalization rate increased.
2., in the current clinical practice, the diagnosis and treatment of head and neck radiotherapy related OM is still not standardized, and the rate of missed diagnosis is high. There are many kinds of drugs for OM treatment, but most of them are empirical medication, and the implementation of evidence-based medicine is insufficient.
3., a questionnaire survey showed that doctors did not pay much attention to OM. There was a lot of misunderstanding about the theoretical knowledge, including the awareness of diagnosis and treatment guidelines, which led to the misunderstanding of OM prevention and treatment. It highlighted the necessity of training OM oncology related knowledge for oncologists.

【学位授予单位】：华中科技大学
【学位级别】：博士
【学位授予年份】：2014
【分类号】：R739.91

【共引文献】