提升癌症免疫治療照護品質之衛教流程: 以強化病患自我識能模式

Abstract

不論從台灣癌症統計數字的改善或是全球癌症治療的進展，都不難看出整體癌症治療品質已逐漸提升，以及癌症呈現慢性病化的發展趨勢，病患與癌症和平共存的機會增加，尤其癌症免疫治療於近十年蓬勃發展，成就許多受益於免疫治療的「癌症倖存者」，然而，免疫療法在延長病患生存期的同時，也帶給病患副作用管理以及經濟負擔的壓力，加上抗癌過程中亦須面對心理方面的衝擊，種種障礙導致病患在維持穩定免疫治療的過程相當艱辛，此時癌症照護團隊的介入輔導及衛教支持，在幫助病患持續癌症免疫治療過程中扮演相當重要的角色。故本研究針對癌症免疫療法的照護及衛教流程，深入探討其中影響病患治療決策的考量因素。本研究採用「個案研究法」與「半結構式訪談法」，以個案訪談的方式記錄個案管理師的照護及衛教經驗，將訪談內容以跨個案的方式做分類整合，再導入自我識能理論的SDT-based策略編碼進行綜合分析。研究結果針對免疫檢查點抑制劑治療的病患旅程，分為四個不同的治療決策階段以及其中的關鍵決策考量點，依據分析結果，在各個治療決策階段，病患的經濟負擔能力、副作用管理、療效期望值以及心理壓力，都會對於決策考量點的路徑選擇造成影響，也是個案管理師進行衛教時所關注的重點，而以SDT-based策略模式來看，決策前期階段的目標為滿足病患的自主(Autonomy)需求，至決策中間階段延伸至更多相關能力(Competency)培養，以及透過社會相關性(Relatedness)強化自主與能力，提升病患的信心以維持穩定的免疫治療，而三大需求目標各有三項具有主導性及影響力之SDT-based策略。由此可知，透過提升病患自我識能的策略運用於免疫檢查點抑制劑的照護與衛教過程，有助於降低病患在治療過程中可能遇到的困難與心理障礙，延長病患持續獲得治療益處的時間，提升癌症免疫治療與照護品質。

Both the improvement in cancer statistics of Taiwan and the progress in global cancer treatments clearly indicate that the overall quality of cancer care has gradually improved, and cancer is increasingly becoming a chronic condition. With continuous advancements in the medical environment and technology, the chances for patients to coexist peacefully with cancer are rising. Notably, cancer immunotherapy has seen significant growth in the past decade, benefiting many "cancer survivors" through this treatment. However, while immunotherapy extends patients' survival periods, it also brings challenges in managing side effects and economic burdens. Additionally, patients must confront psychological impacts during their cancer battle. These obstacles make it challenging for patients to maintain stable immunotherapy. Hence, the intervention and support of cancer care teams play a crucial role in helping patients through their immunotherapy journey. This study delves into the care and educational processes of cancer immunotherapy, exploring factors influencing patients' treatment decisions and how cancer case managers can assist in enhancing the quality of cancer care and education. The research employs the "case study method" and "semi-structured interviews," documenting the care and educational experiences of four cancer case managers through interviews. The interview content is categorized and integrated across cases, followed by a comprehensive analysis using decision factors from the Self-Determination Theory (SDT). The study results identify four distinct treatment decision stages and their key decision considerations in the patient journey for those treated with immune checkpoint inhibitors. The analysis shows that regardless of the treatment decision stage, patients' economic burden capacity, side effect management, treatment efficacy expectations, and psychological stress significantly influence decision pathways. These factors are also the focus areas for case managers during education. From an SDT-based strategic model perspective, the early decision stage aims to meet patients' autonomy needs, the middle stage gradually cultivates relevant competencies and strengthens social relatedness, and the later stage builds on autonomy and competence with added social support. Therefore, meeting patients' three basic needs outlined by the Self-Determination Theory helps them achieve the best treatment experience during immunotherapy, maintain stable treatment confidence, and enhance the quality of cancer care and education.