乳癌病人併發第二原發癌醫療利用,費用及其影響因素之探討

Medical Utilization, Cost and Risk Factors in Breast Cancer Patients with Second Primary Cancer

張凱翔(Kai-hsiang Chang)

指導教授 ： 張肇松

高雄醫學大學/健康科學院/醫務管理暨醫療資訊學系碩士班/碩士(2013年)

摘要

研究背景與動機
依世界衛生組織(World Health Organization，WHO)2008年統計資料顯示，全球約有1200萬名新發生癌症個案。癌症乃係屬台灣重大傷病，其中以乳癌為女性癌症發生率最高的癌症，顯示出乳癌對台灣女性健康的威脅性。因此本研究欲探討台灣乳癌病人終身之第二原發癌(SPC)發生情形與影響因素、醫療費用、醫療資源利用情形、存活天數差異
研究方法
本研究為世代追蹤型研究(cohort study)，追蹤期間為1997年1月1日至2008年12月31日，從健保資料庫重大傷病檔中挑選出乳癌患者有登記死亡日期的個案，再從中挑選乳癌一個月後罹患第二原發癌者，找出病患的接受過的治療方式，包括是否接受手術、化學治療、放射線治療、賀爾蒙治療、標靶治療，分析其醫療資源利用、費用與病患存活天數。本研究以卡方檢定、獨立樣本T檢定與對數回歸分析，進行資料描述性統計及推論性統計分析；以SAS 9.3版進行傾向分數配對。
研究結果
本研究中乳癌病人擁有第二原發癌者有80位，以消化器官及腹膜之惡性腫瘤19位最多，裡面分別為食道惡性腫瘤2位佔2.5%、胃惡性腫瘤5位佔6.25%、小腸惡性腫瘤1位佔1.25%、直腸與直腸乙狀結腸連接部及肛門之惡性腫瘤1位佔1.25%、肝及肝內膽管惡性腫瘤9位佔11.25%、消化器官及腹膜內之其他惡性腫瘤1位1.25%。呼吸道及胸內器官之惡性腫瘤17位(21.25%)次之，分別為氣管與支氣管及肺之惡性腫瘤15位佔18.75%，胸(肋)膜惡性腫瘤1位佔1.25%，胸腺、心臟及縱膈之惡性腫瘤1位佔1.25%。生殖泌尿器官惡性腫瘤12位(15%)，分別為子宮頸惡性腫瘤4位佔5%，胎盤惡性腫瘤1位佔1.25%，子宮體惡性腫瘤1位佔1.25%，卵巢及其他子宮附屬器官之惡性腫瘤2位佔2.5%，其他女性生殖器官之惡性腫瘤1位佔1.25%，膀胱惡性腫瘤2位佔2.5%，腎臟及其他泌尿器官之惡性腫瘤1位佔1.25%。骨骼、結締組織、皮層之惡性腫瘤9位(11.25%)，分別為骨骼及關節軟骨之惡性腫瘤4位佔5%，結締組織及其他軟組織之惡性腫瘤1位佔1.25%，皮膚之其他惡性腫瘤3位佔3.75%，卡波西氏肉瘤1位佔1.25%。唇、口腔及咽部之惡性腫瘤4位(5%)，分別為主要唾液腺惡性腫瘤1位佔1.25%，鼻咽惡性腫瘤2位佔2.5%，唇、口腔及咽其他惡性腫瘤1位佔1.25%，原位癌3位(3.75%)為生殖泌尿系統原位癌，淋巴及造血組織之惡性腫瘤2位(2.5%)，分別為淋巴性白血病1位佔1.25%，細胞型態不明之白血病1位佔1.25%。
結論與建議
本研究發現第二原發癌分布以消化器官及腹膜之惡性腫瘤最多佔23.75%，其次為呼吸道及胸內器官之惡性腫瘤佔21.25%、生殖泌尿器官惡性腫瘤佔15.00%、骨骼與結締組織及皮層之惡性腫瘤佔11.25%、唇與口腔及咽部之惡性腫瘤佔5.00%、原位癌佔3.75%、淋巴及造血組織之惡性腫瘤佔2.5%，然後還有其他20%。
針對第二原發癌影響因子為合併症分數、有無進行手術、有無進行放射線治療，合併症分數每增加一分，第二原發癌風險就增加1.22倍(95%信賴區間為1.09-1.36)；相較於無進行手術者，手術病患的第二原發癌風險增加4.15倍(95%信賴區間為1.48-11.60)；相較於無進行放射線治療者，接受放射性治療病患的第二原發癌風險增加2.72倍(95%信賴區間為1.71-4.32)。

關鍵字

乳癌 ； 第二原發癌

並列摘要

Abstract
Background and Objective
According to the data of World Health Organization ( WHO ) in 2008 show that there are about 12 million new cancer patients around the world. Cancer is one of the serious illnesses and injury in Taiwan. And the incidence of breast cancer (BC) for women is high. It’s a serious problem for Taiwan female. We want to compare the medical cost, medical utilization and survival day between two types of the BC patients (second primary cancer vs. non-second primary cancer). We also want to know the factors of the BC patient with second primary cancer.
Method
This cohort study investigates the patient with breast cancer that also diagnosed as second primary cancer patient’s medical resource usage and expense in their life-time. Patients who were diagnosed as breast cancer and died (according to Registry for Catastrophic Illness Patients of NHI) between 1997 and 2008 were enrolled for our study. According to different treatments( included surgery, chemotherapy, radiation therapy, hormone therapy, targeted therapy) ,we analyzed the medical utilization, cost and survival day. Statistical analysis including descriptive statistics and inferential ststistics e.g. χ2-test, T-test, logistic linear regression were performed using SPSS 19.0 software. Propensity score was performed using SAS 9.3 software.
Results
The total cases of SPC in our study is 80. The frequency of Malignant neoplasm as following with esophagus 2.5% ; stomach 6.25% ; small intestine 1.25% ; rectum, rectosigmoid junction, and anus 1.25% ; liver and intrahepatic bile ducts 11.25% ; other and ill-defined sites within the digestive organs and peritoneum1.25% ; trachea, bronchus, and lung 18.75% ; pleura1.25% ; thymus, heart, and mediastinum1.25% ; cervix uteri 5% ; placenta1.25% ; uterus1.25% ; ovary and other uterine adnexa 2.5% ; other and unspecified female genital organs 1.25% ; bladder2.5% ; kidney and other and unspecified urinary organs 1.25% ; bone and articular cartilage 5% ; connective and other soft tissue 1.25% ; Other malignant neoplasm of skin 3.75% ; Kaposi's sarcoma 1.25% ; major salivary glands 1.25% ; nasopharynx 2.5% ; other and ill-defined sites within the lip, oral cavity, and pharynx 1.25% ; Acariasis 3.75% ; Lymphoid leukemia 1.25% ; Leukemia of unspecified cell type 1.25% ; eye 1.25% ; brain 5% ; other and unspecified parts of nervous system 1.25% ; thyroid gland 1.25% ; other and ill-defined sites 2.5% ; Neoplasm of uncertain behavior of endocrine glands and nervous system 1.2% ; uncertain behavior of other and unspecified sites and tissues 1.25% ; Neoplasms of unspecified nature 6.25%.
Conclusion and Suggestion
The frequency of second primary cancer in this study as following with malignant neoplasm of digestive organs and peritoneum 23.75% ; Malignant neoplasm of respiratory and intrathoracic organs 21.25% ; Malignant neoplasm of genitourinary organs 15.00% ; Malignant neoplasm of bone, connective tissue, skin, and breast 11.25% ; Malignant neoplasm of lip, oral cavity, and pharynx 5.00% ; Acariasis 3.75% ; Malignant neoplasm of lymphatic and hematopoietic tissue 2.5% ; other 20.00%.
The surgery, radiation therapy and CCI have a significant impact on second primary cancer. The odds ratio of CCI is 1.22(95% C.I=1.09-1.36). The odds ratio of surgery is 4.15(95% C.I=1.48-11.60) .The odds ratio of radiation therapy is 2.72(95% C.I=1.71-4.32).

並列關鍵字

Breast cancer ； Second Primary Cancer

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