營養諮商與運動方案對接受放射治療合併化學治療之食道癌病患改善成效之探討

Abstract

食道癌病人營養不良的盛行率高達78.9%，居所有癌症病人之冠。文獻證實營養不良會增加病患感染的風險、治療的副作用與醫療的支出，並降低整體治療成效、生活品質和存活率。本研究聚焦於研擬一套兼具營養諮詢與運動措施的非侵入性照護方案，並探討此方案是否能改善病患的營養狀況，並減少治療相關的副作用與治療的中斷。 研究採分層隨機且單盲之實驗性研究設計，以初次診斷食道癌並接受放射治療合併化學治療之患者為對象，採隨機方式分派至實驗組與對照組，實驗組接受4週的營養諮商與運動方案，對照組則接受一般常規護理衛教，實驗結果以體重、身體脂肪/肌肉分析、握力、六分鐘行走測驗、治療副作用毒性、血液生化值及治療中斷次數等指標來評量。所得資料以卡方、Fisher’s exact test、獨立樣本t檢定來檢定兩組病人的基本屬性與生理測量變項，檢驗之顯著差異水準定為p<0.05。 結果依據36名病患之資料分析，平均年齡59.8±11歲(35名男性，97.2%為鱗狀上皮細胞癌)。兩組病患在基本屬性、疾病資料、營養狀況、體重、進食方式、吞嚥功能、握力及體能等均無顯著差異。在營養成效上，實驗組病人在治療結束時體重-1.7%±3.2，對照組-5.8%±3.0，達到顯著差異(p<0.001)；實驗組的握力-1.2公斤，對照組-4.3公斤 (p=0.017)；六分鐘行走距離實驗組縮短了5.6公尺，對照組縮短了145.6公尺(p=0.006)，顯示營養諮詢與運動方案對於維持病人的體重、握力、運動能力等項目有顯著的效果。在治療副作用方面，對照組比實驗組病人更容易發Gr.2 以上的嗜中性白血球低下(p=0.041)，且對照組病人需要靜脈輸液與輪椅的比率，明顯高於實驗組(p=0.003和p=0.045)，顯示對照組病人在治療期間，其營養狀況與體能明顯變差。 研究結果顯示，此營養諮詢與運動方案可有效改善食道癌病患的營養，增加病患對治療的接受度。然而，其成效是否能持續，有待未來進一步的研究。

The prevalence of malnutrition in patients with esophageal cancer is estimated to be as high as 78.9% and malnutrition increases the risk of treatment toxicity and decreases treatment response. The aim of this study was to test the effects of a nurse-led intervention on nutritional outcomes and treatment toxicity in patients undergoing chemoradiation for esophageal cancer. This was a single blind, one-center, randomized controlled clinical trial. Consecutive patients with locally advanced esophageal cancer, scheduled to receive neoadjuvant chemoradiation were enrolled. Participants were stratified by route of intake (oral vs. tube-fed) and randomly assigned to the experimental or control groups under a separate randomization scheme. During 4 weeks of chemoradiation, participants in the experimental group, additional to the usual care, received weekly individual-tailored nutrition counseling and 3 times a week walking intervention from a trained nurse practitioner. Participants in the control group received usual care. Primary outcomes included hand-grip strength, body weight, soft lean mass measured by bioelectrical impedance analysis, and walking distances measured by the 6-min walk test. Secondary outcomes included numbers of treatment break/delay, incidences of chemoradiation-related toxicity (grade 2 and above ), and numbers of unplanned hospitalization. A total of 36 participants (35 males, 1 female; mean age, 59.8±11 years; 97.2% of squamous cell carcinoma) were randomized to receive either intervention (n=18) or usual care (n=18). No significant differences at baseline characteristics were identified groups. Upon completion of 4-week chemoradiation, participants received intervention, compared with those received usual care, experienced less weight loss (mean weight change -1.7% vs. -5.8%, p<0.001), less hand-grip strengths reduction (-1.2kg vs. -4.3kg, p=0.017), less walking distance reduction (-5.6m vs. -145.6m, p=0.006), fewer episodes of ≧Gr.2 neutropenia (6% vs.38.9%, p=0.041), fewer episodes of intravenous nutritional support (p=0.003), and less wheelchair used (p=0.045). The findings indicated that this nurse-led intervention is beneficial on nutritional outcomes and treatment toxicity for patients with esophageal cancer who undergoing chemoradiation. Further research with a larger sample is required to investigate the long-term effectiveness and identify factors associated with outcome variation.