整合性護理介入對食道癌患者的營養、身體功能、情緒安適及生活品質之成效

Abstract

研究背景與目的：食道癌是一個高度惡性的癌症，治療相當艱辛與漫長，多數病人確診時已屬中晚期，需先接受前導性放射化學治療(neoadjuvant concurrent chemoradiotherapy; CCRT)縮小腫瘤，再接受食道切除與重建手術。治療期間，病人的營養、身體功能、情緒安適與生活品質均持續惡化，使得術後肺部合併症的發生率居高不下。本研究結合營養衛教、走路運動與吸氣肌訓練，形成一套整合性的術前護理介入方案，研究的目的即在測試此介入方案，是否可維持並改善CCRT到食道切除手術後一個月，食道癌病人的營養、身體功能、情緒安適與生活品質，同時降低術後肺部合併症，並縮短住院天數。 研究方法：本研究採分層隨機且單盲之實驗性研究設計，以初次診斷為食道癌，臨床期別IIB以上，預定接受前導性放射化學治療與食道切除與重建手術之患者為對象，隨機分派為實驗組及對照組。實驗組接受整合性護理介入方案，對照組接受常規照護。兩組分別於前導性放射化學治療前(T0)、前導性放射化學治療結束時(T1)、食道切除與重建手術前(T2)、及手術後一個月(T3)，評估其營養(體重、肌肉質量)、身體功能(握力、六分鐘步行距離、最大吸氣壓力)、情緒安適(焦慮、憂鬱症狀)與生活品質(症狀困擾)等主要結果指標；此外，次要指標如術後肺部合併症、呼吸器使用時數、住院天數等亦一併檢視。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，以Paired t-test、McNemar’s test 或 General estimating equation (GEE)進行不同時間點之組內成效比較，以Independent t-test或General estimating equation (GEE)比較兩組之組間成效差異。檢驗之顯著差異水準定為p<0.05。 研究結果：本研究共收案85名病患，其中介入組為42名，對照組為43名。病患平均年齡59.8±9.6歲(89.4%為男性，90.6%為鱗狀上皮細胞癌)。兩組病患在基本屬性、疾病資料、治療藥物與劑量、生理測量等均無顯著差異。在CCRT到手術前這段期間，介入組病人的體重、六分鐘走路距離、最大吸氣壓力均顯著優於對照組，顯示整合性護理介入可在手術前有效維持病人的營養，提升病人的身體活動量與吸氣肌肌力。然而，病人在治療期間的情緒困擾如焦慮、憂鬱與生活品質，兩組病人並沒有顯著的差異。兩組病人的術後肺部合併症發生率、插管時數與住院天數也並未達到統計顯著。 結論：研究結果顯示此術前介入方案具有臨床可行性，從CCRT治療到手術前，此整合性護理介入可改善食道癌病人的體重減輕，增加身體活動量，並提升呼吸肌肌力。

Backgroud: Esophageal cancer is a devastating disease with poor prognosis. This is largely due to its rather insidious progression, so most patients were diagnosed with advanced cancer stage. Patients with advanced stage therefore have to be treated with neoadjuvant chemoradiotherapy (CCRT) to shrink the tumor and followed by a curative surgery (esophagectomy). Patients’ nutritional status, physical functioning, emotional well-being, and quality of life are substantially deteriorated during CCRT, which often increase the incidence of postoperative pulmonary complications. To better support patients with esophageal cancer during this critical treatment course (approximate 4 months in length), we developed a “Walk, Eat, & Breathe” nursing intervention consisting of nutritional advice, walking exercise, and inspiratory muscle training. The purpose of this study was to test the effects of a comprehensive nursing intervention (Walk, Eat, & Breathe) on preserving patients’ nutritional status, physical functioning, emotional well-being, and quality of life during the CCRT and surgery course. Additionally, effects to reduce postoperative pulmonary complications and length of hospital stay for esophagectomy were also evaluated between experimental and control groups. Method: This was a single-blinded, stratified randomized controlled clinical trial. Consecutive patients were eligible for the study if they had histologically documented, locally advanced tumors of the esophagus, defined as American Joint Committee on Cancer (AJCC) stage IIB or higher, scheduled for neoadjuvant chemoradiotherapy and subsequent curative surgery. After obtaining the consent, participants were stratified by two important covariates of intake status (oral intake or tube feeding) and tumor location (upper third or middle & lower third of esophagus)] and then randomized separately into the experimental or control group, according to computer-generated randomization tables. Participants in the experimental group received “Walk, Eat, & Breathe” at initiation of CCRT and ends before curative surgery. Participants in the control group received usual care. Participants underwent measurements at four points in time: before CCRT (T0), after CCRT (T1), before surgery (T2), and 1-month after surgery (T3). Primary endpoints included nutritional status (body weight, lean muscle mass), physical functioning (hand-grip strength, 6-min walking distance, maximal inspiratory pressure), emotional well-being (anxiety, depression), and quality of life. Secondary endpoints included incidence of postoperative pulmonary complications, length of mechanical ventilation, and length of hospital stay for esophagectomy. Descriptive statistics were used to analyse baseline demographic variables. Differences in outcomes variables within-group were tested with the paired t-test, McNemar’s test, or General estimating equation (GEE). Differences in outcome variables between the intervention and control group were tested with the chi-square or Fisher’s exact test for categorical data and with the independent t-test or GEE for continuous data. A two-sided P value of less than 0.05 was regarded as significant. Results: Eighty-five patients were included, of which 42 received comprehensive nursing intervention. Participants (mean age = 59.8 years) were mostly males (89.4%) with squamous-cell carcinoma (90.6%). Participants in the intervention and usual care groups did not differ in other baseline characteristics. During chemoradiotherapy, participants who received “Walk, Eat, & Breathe” intervention had less weight loss and better walking capacity and inspiratory muscle strength. However, there was no statistically significant difference in anxiety, depression, and quality of life between the groups. The incidence of postoperative pulmonary complications and length of stay were also comparable between the two groups. Conclusion: The comprehensive nursing intervention is feasible in patients with esophageal cancer and significantly improved body weight loss, walking capacity, and inspiratory muscle strength before surgery. This, however, did not result in a reduction of postoperative pulmonary complications and length of stay in patients undergoing esophagectomy.