探討晚期癌症病患之體能、身體活動與身體功能之變化、相關性與影響

Abstract

研究背景：身體功能為癌症患者病況變化與治療效果之重要指標，由於病情進展與治療副作用影響，癌症患者之功能衰退較未罹癌者更加急遽，導致病人與家屬在短時間內身心承受巨大衝擊。近年來許多研究指出身體活動可提升癌症患者之功能，但研究對象限於早期與特定癌別患者，於晚期甚至生命末期癌症患者之有效證據仍非常稀少，因此，本研究欲觀察晚期癌症患者中，身體活動對其身體功能是否具正面影響，並期許此前驅性研究能鼓勵後續研究介入活動措施，減緩晚期癌症患者之功能衰退。 研究目的：調查晚期癌症病患之體能、身體活動與身體功能於生命末期之變化軌跡（Trajectory）與相關性。 研究方法：本研究為一縱貫性觀察型研究，自2023年9月至2024年5月，於台灣北部某醫學中心之安寧與腫瘤科病房進行收案，共納入40位晚期癌症病患。收案條件為：大於等於18歲、診斷為晚期癌症且預估存活期小於6週。預估存活期以緩和預後量表（Palliative Prognostic Scale, PPI）進行篩選，納入個案得分需大於4分。排除條件為：因意識或認知狀況無法配合儀器量測者、血液腫瘤患者、因初次診斷癌症入院之患者。研究工具包含自擬檢查表、埃德蒙頓症狀評估系統（Edmonton Symptom Assessment Scale, ESAS）量表與非侵入性裝置（身體活動量紀錄器與生物抗阻分析儀）。體能與症狀困擾以生物抗阻分析儀、肌力測試與問卷評分每周進行追蹤；身體活動以貼身活動紀錄器進行每日資料蒐集；身體功能由研究人員以緩和身體活動功能評估量表（Palliative Performance Scale, PPS）每周進行評分。 結果：研究結果以描述性統計、皮爾森積差相關、線性迴歸與多重迴歸進行資料分析。追蹤期間共32位（80%）患者過世，收案後之平均死亡時間（Mean time to death）為3.07週（SD = 4.65）。個案之平均年齡為65.95 ± 12.27歲，以男性居多（55%），癌症診斷主要為消化系統癌症（36.96%）與肺癌（23.91%）。患者平均佩戴活動記錄器（Actigraphy）時間為9.87（SD = 6.12）天，每小時平均活動量為2.86（SD = 1.70）kcal，平均活動強度為1.03 METs（SD = 0.010），所有患者之平均活動強度均屬於靜態活動（Sedentary Behavior, MET ≤ 1.5）。收案當下患者之身體功能（PPS）平均得分為37.25％（SD = 10.62），最小值為20%，最大值為60%。死亡前之變化軌跡中，體能中之肌力約於死亡前一周開始下降；身體組成中的脂肪量逐漸下降伴隨體細胞重輕微上升。身體活動於觀察期間均偏低，變化不明顯；而身體功能則是顯著下降。相關分析中顯示體能中之脂肪量與次周、隔週之身體活動間存在顯著正相關（all p < 0.05）；身體活動量與活動強度均與身體功能間存在顯著正相關（r = 0.618, p = 0.043；r = 0.726, p = 0.043）；身體活動強度與症狀困擾（食慾不振與焦慮）存在負相關（r = -0.488, p = 0.034；r = -0.524, p = 0.026）。迴歸模型中，死亡前第二周之脂肪量可預測次周之身體活動（F =5.236, p = 0.021）；死亡前一周身體活動可預測次周之身體功能（F = 5.027，p = 0.039）。脂肪量可預測身體活動，而身體活動可作為晚期癌症患者預測身體功能的指標之一。此外，身體活動強度可影響症狀困擾。 結論：本研究為極少數探討生命末期晚期癌症患者之體能、身體活動與身體功能變化之本土研究。研究結果顯示，在晚期癌症患者之生命末期階段，體能、身體活動與身體功能均有不同程度之衰退，體能中之身體組成—脂肪量，為可預測身體活動下降的潛在指標；而身體活動可預測身體功能下降。即使於生命末期，維持身體活動仍有助於維持癌症患者之身體功能。

Background: Physical function is a crucial indicator of disease progression and treatment efficacy in cancer patients. Due to the progression of the disease and the side effects of treatment, functional decline in cancer patients is more rapid and severe compared to non-cancer patients, causing significant physical and emotional distress to both patients and their families in a short period. Recent studies have shown that physical activity can improve the functional status of cancer patients, but the research has primarily focused on early-stage and specific types of cancer. There remains a scarcity of robust evidence regarding the effects of physical activity on patients with advanced cancer, especially at the end of life. Therefore, this study aims to observe whether physical activity positively influences the functional status of patients with advanced cancer. It is hoped that this study will encourage further research on physical activity interventions to slow the functional decline in advanced cancer patients. Methods: This longitudinal observational study was conducted from September 2023 to May 2024 in the palliative care and oncology wards of a medical center in northern Taiwan. A total of 40 advanced cancer patients were enrolled. Inclusion criteria were: age 18 or older, diagnosed with advanced cancer, and an estimated survival of less than 6 weeks (Palliative Prognostic Index, PPI > 4). Exclusion criteria included inability to comply with device measurements due to consciousness or cognitive issues, hematologic malignancies, and newly diagnosed cancer patients. Data were collected using self-designed checklists, the Edmonton Symptom Assessment Scale (ESAS), and non-invasive devices (activity trackers and bioelectrical impedance analysis). Patients wore activity monitors during the study period to record physical activity. Weekly assessments of body composition, muscle strength tests, and questionnaire administration were conducted to document physical fitness and symptom burden. The Palliative Performance Scale (PPS) was used to evaluate physical function. Results: Descriptive statistics, Pearson correlation, linear regression, and multiple regression were used for data analysis. Data from 40 patients (mean age = 65.95±12.27), with a predominance of males (22, 55%), were analyzed. The primary cancer diagnoses were gastrointestinal cancers (36.96%) and lung cancer (23.91%). During the study period, 32 patients (80%) died, with a mean time to death of 3.07 weeks (SD = 4.65) upon approach. Patients wore the activity tracker for an average of 9.87 days (SD = 6.12), with an hourly average activity level of 2.86 kcal (SD = 1.70) and an average activity intensity of 1.03 METs (Metabolic Equivalent, SD = 0.010). All activities were classified as sedentary which is defined as METs ≤ 1.5. The average PPS score when approached was 37.25% (SD =10.62). In the trajectory of changes before death, muscle strength began to decline approximately one week before death, while fat mass gradually decreased, accompanied by a slight increase in somatic cell mass. Physical activity remained low during the observation period, with minimal changes, while physical function declined significantly. Correlation analysis revealed a significant positive association between fat mass and subsequent weekly physical activity (all p < 0.05). Physical activity, including energy expenditure and activity intensity, were significantly positively correlated with physical function in the following week (r = 0.618, p = 0.043; r = 0.726, p = 0.043), while physical activity intensity was significantly negatively correlated with symptom burden (appetite loss and anxiety) (r = -0.488, p = 0.034; r = -0.524, p = 0.026). In the regression model, fat mass in the second week before death significantly predicted physical activity in the following week, F (EE, fat) = 5.236, p = 0.021. Physical activity in the week before death predicted physical function in the subsequent week (F = 5.027, p = 0.039). Fat mass can predict physical activity and physical activity can be a predictor of physical function in patients with advanced cancer. Additionally, physical activity intensity influences symptom burden. Conclusions. This study is one of the few local studies exploring changes in physical fitness, physical activity, and physical function among advanced cancer patients at the end of life. The results indicate that in advanced cancer patients, there is a varying degree of decline in physical fitness, physical activity, and physical function toward the end of life. Body composition, particularly fat mass, is a potential indicator of declining physical activity, while physical activity may serve as a predictor of physical function. Enhancing physical activity could be a potential strategy to maintain physical function in terminal cancer patients.