334例肺癌患者终末期治疗的回顾性研究

发布时间：2018-04-16 14:39

本文选题：晚期肺癌 + 治疗模式　；参考：《北京中医药大学》2015年博士论文

【摘要】：[研究背景]肺癌发病率及死亡率居全世界第一,2012年约新增180万患者,死亡约159万人,分别占全球肺癌新发病例及死亡病例的13%及18%。肺癌在我国的发病率与死亡率也均居于首位,2011年全国新发肺癌病例约65万,死亡约52万。肺癌早期可无症状,早期诊断率仅有15%,80%患者在诊断时已是局部晚期或有远处转移,失去积极治疗机会,治疗效果差。虽然肺癌的多学科综合治疗技术有了很大的进步,但肺癌患者5年生存率仍只有10%-15%,并且,多数治疗都具有一定副作用,给患者机体带来负担。NCCN指南以生存期延长及肿瘤缩小作为治疗效果的评价指标,并未从患者方面来评价治疗效果,如何在延长生存期的同时提高生活质量是我们一直力求解决的问题。现代医学治疗手段并不能治愈所有癌症,肿瘤患者终末期仍意味着极度痛苦、衰竭和死亡。晚期肿瘤患者由于肿瘤消耗及长期反复治疗,体质较弱,生活不能自理,并患有多个症状,如癌性疼痛、胸腹水、乏力、不能进食、呼吸困难等,甚至伴有恶病质,生活质量差。据调查,76.4%家属及77.1%患者认为当病情不可逆转时,以减轻痛苦为主,并希望有尊严、无痛苦的安乐死；目前在我国,仍有50%甚至更多的治疗费用用于延长晚期肿瘤患者痛苦的死亡过程,而这并不能对癌症治疗产生实质性进展,也不利于患者在生命最后阶段的舒适、满足,更不利于有限医疗资料的有效利用。肿瘤患者终末期身心承受着巨大痛苦,而我国目前姑息治疗和临终关怀事业开展受限,如何减轻肿瘤患者终末期症状,提高晚期肺癌患者生活质量是我们临床急需解决的问题。基于以上,我们提出以中医药为主体的肿瘤治疗模式。中医药治疗肿瘤有丰富的理论知识和临床经验,中医药以传统中医理论为指导,辨证论治为原则,对患者进行个体化治疗,以减轻患者症状、提高患者生活质量为出发点,通过激发人体免疫力对抗肿瘤,改善放化疗毒副反应,提高患者生存质量,减缓病情发展,延长患者生存期。中西医相互结合,采用低损伤、无毒副作用、较为安全的手段治疗肿瘤的综合治疗方案。《NCCN肿瘤学临床实践指南》是由美国国立综合癌症网络(NCCN)制定的临床实践指南,是美国肿瘤领域甚至全球肿瘤临床实践应用最广泛的指南,但未提及中医药治疗肿瘤的临床研究和疗效。如何发挥中医药优势,创造适合中国肿瘤患者的肿瘤综合治疗模式是目前我们临床面临的直接问题。[研究目的]1.分析肺癌患者临终前六个月治疗手段,了解肿瘤患者临终前治疗手段的选择情况；通过分析患者临终前六个月支持手段及症状缓解的情况,寻求肿瘤终末期的最佳治疗手段,为以中医药为主体的治疗模式作为肿瘤终末期治疗手段提供临床依据；2.通过对病例进行回顾性研究,探讨中西医结合治疗晚期肺癌的临床疗效；通过分析中西医结合治疗对晚期肺癌生存期的影响,为以中医药为主体的治疗模式治疗晚期肺癌提供可靠的临床依据；3.探索如何发挥中医药优势,创造适合我国晚期肺癌患者的最佳治疗模式,为临床治疗提供参考。[研究方法]本研究采用回顾性研究方法总结2009年10月至2014年11月在东方医院肿瘤科住院的肺癌死亡病例334例,统计患者总治疗手段和临终前6个月治疗手段,归纳治疗模式,分析各治疗模式对生存期的影响；对临终前6个月患者所使用的支持手段进行分析,探讨临终前6个月治疗手段与支持手段的相关性,对以中医药为主体的治疗模式作为终末期肿瘤患者治疗手段的临床价值进行评估。[结果]1.人口学及肿瘤相关因素分析：男女比例约为2：1;68.3%为老年患者,其中以70-79岁人数最多,占39.5%；男性以小细胞和鳞癌居多,女性以非吸烟腺癌者居多；87.4%患者确诊时已为肺癌中晚期；2.不同治疗模式对生存期影响：晚期小细胞肺癌：传统治疗可延长晚期小细胞肺癌生存期(P0.05)；单纯中医未能使晚期小细胞肺癌生存期获益；非小细胞肺癌：综合治疗和传统治疗均可延长晚期肺鳞癌患者生存期生存期(P0.05),但两者间无统计学差异(P0.05)；靶向治疗未能使肺鳞癌患者获益(P0.05)；综合治疗使肺腺癌生存期获益最大,其次是传统模式(P0.05),两组有统计学差异；靶向治疗可延长晚期病理类型不详者的生存期(P0.05)；3.中西医结合综合治疗对生存期影响：在本课题中,中西医结合治疗晚期非小细胞肺癌与单纯西医治疗的相关文献相比,可使患者生存期明显获益；4.对生存期进行COX分析,结果显示吸烟、家族肺癌史、手术、放疗、化疗是生存期的影响因素。吸烟史是生存期的危险因素(B=0.339,RR=I.403),家族肺癌史(B=-0.793,RR=0.454)、手术(B=-1.002,RR=0.367)、放疗(B=-0.363,RR=0.696)、化疗(B=-0.751,RR=0.472)四者是生存期的有利因素。5.临终前6个月治疗模式的选择：有47.4%患者选择单纯中医支持治疗；40.0%患者仍选择放化疗等损伤性抗肿瘤治疗,约12.5%患者选择靶向治疗。6.肺癌患者临终前6个月支持手段的影响因素：肺癌终末期接受单纯中医治疗者,其临终前6个月的输血率、升血针使用率、止疼药使用率、茶碱使用率和使用天数、积液产生率、镇静药使用天数、止血药使用率、住院天数明显低于中西医结合组(P0.05)；而激素的使用率和使用天数也低于中西医结合组(P0.1)；7.对于生存期较长病例进行分析：腺癌和鳞癌明显优于小细胞癌,腺癌与鳞癌差别并不明显,但在2年以上生存方面腺癌优势明显,性别方面,男女在各个阶段比例差异并不明显；[结论]1.早期积极综合治疗可使晚期肺癌患者生存期获益,生存期得到延长；2.在本课题中,中西医结合治疗晚期非小细胞肺癌与单纯西医治疗的相关文献相比,可延长患者生存期；3.本课题显示约47.4%患者在终末期选择单纯中医药支持治疗,40%患者仍选择具有损伤性的抗肿瘤治疗作为终末期治疗；4.单纯中医治疗能明显缓解终末期肺癌患者症状,提高患者终末期生活质量,可作为患者终末期姑息治疗和临终关怀手段之一。
[Abstract]:The morbidity and mortality rate of lung cancer in China is the highest in the world . In 2012 , about 1.8 million patients were killed and about 9 million people died , accounting for 13 % and 18 % of the new cases of lung cancer .
Traditional Chinese medicine is used to treat tumor and improve the quality of life of patients with advanced lung cancer .
Through the analysis of the support means and symptom relief in the last six months of the patient , the best treatment means for the terminal stage of the tumor is sought , which provides the clinical basis for the treatment mode of the main body of the tumor as the treatment means of the end - stage treatment of the tumor ;
2 . To study the clinical effect of integrated traditional Chinese medicine and western medicine in the treatment of advanced lung cancer by retrospective study of cases ;
To provide a reliable clinical basis for the treatment of advanced lung cancer with traditional Chinese medicine as the main body by analyzing the effect of traditional Chinese and western medicine combination therapy on the survival time of advanced lung cancer ;
3 . To explore how to exert the advantages of traditional Chinese medicine and to create the best mode of treatment suitable for patients with advanced lung cancer in our country . In this study , 334 cases of lung cancer deaths hospitalized in the East Hospital Oncology Department from October 2009 to November 2014 were summarized in this study .
This paper analyzes the supporting methods used by patients in the last 6 months , and discusses the correlation between the treatment methods and the supportive measures in the last 6 months , and evaluates the clinical value of the treatment modality as the main body in the last 6 months . The results indicate that the proportion of men and women is about 2 : 1 ; 68.3 % is the elderly patients , among them the number of people aged 70 - 79 is the largest , accounting for 39.5 % ;
in men , small cell and squamous cell carcinoma , women are mostly non - smokers ;
87.4 % of patients were diagnosed with advanced lung cancer .
2 . Effect of different treatment modes on survival time : advanced small cell lung cancer : traditional treatment can prolong the survival time of advanced small cell lung cancer ( P0.05 ) ;
Traditional Chinese medicine fails to benefit the survival period of advanced small cell lung cancer ;
Non - small cell lung cancer : comprehensive treatment and traditional treatment could prolong the survival time of patients with advanced lung squamous cell carcinoma ( P0.05 ) , but there was no statistical difference between them ( P0.05 ) .
Targeting therapy could not benefit patients with squamous cell carcinoma ( P0.05 ) .
The survival time of lung adenocarcinoma was the largest , followed by the traditional model ( P0.05 ) , and there was statistical difference between the two groups .
Targeted therapy can prolong the survival time of patients with advanced pathological type ( P0.05 ) .
3 . The effect of integrated traditional Chinese medicine and western medicine on survival time : In this project , the combination of traditional Chinese medicine and western medicine in the treatment of advanced non - small cell lung cancer can obviously benefit the survival time of patients .
4 . COX analysis showed that smoking , family lung cancer , surgery , radiotherapy and chemotherapy were the influencing factors of survival . The history of smoking was the risk factor for survival ( B = 0.339 , RR = 0.454 ) , the history of family lung cancer ( B = - 0.793 , RR = 0.454 ) , radiation therapy ( B = - 1.002 , RR = 0.367 ) , radiation therapy ( B = - 0.363 , RR = 0.472 ) , chemotherapy ( B = - 0.761 , RR = 0.472 ) , chemotherapy ( B = - 0.751 , RR = 0.472 ) , chemotherapy ( B = - 0.751 , RR = 0.472 ) , and chemotherapy ( B = - 0.751 , RR = 0.472 ) .
40 . 0 % of the patients still chose chemotherapy and other damaging anti - tumor therapy . Approximately 12.5 % of the patients chose targeted therapy . 6 . The patients with lung cancer were treated with the last 6 months . The rate of blood transfusion , the rate of blood transfusion needle , the rate of utilization of blood collection needle , the rate of use of tea base , the number of days of use of sedative drugs , the utilization rate of hemostatic drugs , and the number of days of hospitalization were significantly lower than those of traditional Chinese and western medicine ( P0.05 ) .
However , the utilization rate of hormone and the number of days of use were lower than those of traditional Chinese and western medicine ( P0.1 ) .
7 . Analysis of longer survival cases : adenocarcinoma and squamous cell carcinoma were obviously superior to that of small cell carcinoma , adenocarcinoma and squamous cell carcinoma were not obvious , but the superiority of adenocarcinoma was obvious in more than 2 years .
Conclusion 1 . Early active comprehensive treatment can benefit the survival time of patients with advanced lung cancer and prolong the survival period .
2 . In the present study , the combination of traditional Chinese medicine and western medicine in the treatment of advanced non - small cell lung cancer can prolong the survival time of patients compared with the literature of Western medicine treatment alone .
3 . This study showed that about 47.4 % of patients were treated with pure traditional Chinese medicine at the end of the end , and 40 % still chose the anti - tumor therapy with damage as the end - stage treatment .
4 . Traditional Chinese medicine can obviously relieve the symptoms of terminal - stage lung cancer , improve the quality of life - end life of patients , and can be used as one of the last - stage palliative care and dying care .

【学位授予单位】：北京中医药大学
【学位级别】：博士
【学位授予年份】：2015
【分类号】：R734.2

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