介入口服營養補充品對頭頸癌放射線治療病人營養狀況之影響

Effect of oral nutritional supplements on nutritional status in head and neck cancer patients with radiation therapy

柯淑貞(Shu-Chen Ko)

指導教授 ： 陳曉鈴

中山醫學大學/健康管理學院/營養學研究所/碩士(2014年)

https://doi.org/10.6834/CSMU.2014.00064

摘要

本研究主要目的在探討早期且積極的營養介入並給予口服營養補充品，是否具有下述效益：減少體重及體組成流失、提升癌症患者的營養狀況及生理功能、降低治療中所產生影響進食的副作用，提高放射線治療的完成率及減少腫瘤治療中斷率，進而提升患者的生活品質。研究對象以彰化基督教醫院頭頸癌之新診斷患者，並以門診放射線治療，且年齡介於20歲至80歲，排除年齡20歲以下或80歲以上的患者、懷孕或哺乳及肝腎嚴重衰竭者。研究期間為2012年9月至2013年10月止，共篩選出73名新診斷病人，有53名加入研究計畫並簽署研究同意書，40名資料完整完成統計分析。研究採隨機分組，實驗組於門診放射線治療期間約2個月介入口服營養補充品，每天給予口服營養補充品500卡，對照組則不給予任何營養品補充介入。結果顯示介入口服營養補充品後，病人在熱量攝取、蛋白質攝取量、達熱量建議攝取比例及達蛋白質建議攝取比例皆顯著提升(p<0.05)，在營養狀況方面包括血液學的白血球計數（×103/mm3）、紅血球計數（×106/mm3）、血紅素(g/dl)、血比容Hct (%) 、淋巴球計數(%)、總淋巴球計數（×103/mm3）等之分析，對照組於實驗前後比均有顯著性降低(p<0.05)，實驗組除了白血球計數外還有淋巴球計數 (%)、總淋巴球計數（×103/mm3）有顯著性降低，但兩組間無顯著性差異。而於血清白蛋白方面，兩組都有下降趨勢，但未達統計上顯著差異。體重變化方面所反應的營養效果，對照組與實驗組於第四週即有顯著差異 (p<0.05)；至結束週時差異更加明顯分別為減輕4.6±2.4 公斤與2.6 ±2.4 公斤(p<0.05)，可見營養介入之實驗組體重減輕的情形較緩和。再以體重變化百分比來分析，一樣在第四週時對照組與實驗組即有顯著差異，平均減輕分別為2.9 %與 1.3 % (p<0.05)，至結束週時控制組平均減少6.9±3.2 %而實驗組減少4.1±4.0 % (p<0.05)。隨著治療週數的增加，兩組之病人主觀性營養評估 patient generated subjective global assessment (PGSGA )分數也隨之增加，實驗組於第三、四週後分數趨於穩定，兩組於第六週及結束週時有統計上顯著差異(p<0.05)。檢視試驗期間的體組成變化，兩組在體脂肪量、體水分、除脂肪量都有下降趨勢，兩組間未有統計顯著差異，但對照組下降趨勢比實驗組多，實驗組可保持較穩定的體組成。最後，在臨床治療成效上顯示，實驗組治療中斷五天(治療中斷率)的次數比對照組少(15% 相對於45 %)。實驗組的治療完成率也比對照組高(100% 相對於86%)。本研究結果顯示積極的營養介入並給予口服營養補充品，可達到頭頸癌病人的營養需求量，使其維持適當營養狀況與減少副作用的發生，提升放射線治療的完成率，及減少腫瘤治療中斷率，進而改善頭頸癌病人的生活品質。

關鍵字

頭頸癌 ； 放射線治療 ； 營養狀況 ； 飲食指導 ； 口服營養補充品 ； 副作用 ； 生活品質

並列摘要

Objective
This study was to determine the impact of early and intensive nutrition intervention on a range of outcomes including body weight, body composition, nutritional status, radiotherapy side effect, treatment interruption of radiotherapy, global quality of life (QoL), and physical function compared to usual practice in oncology outpatients receiving radiotherapy in the head and neck cancer patients.

Methods
The patients with head and neck cancer receiving radiotherapy at Changhua Christian Hospital since September 2012 to October 2013. The inclusion criteria were oncology outpatients, age >20 years and<80 years. Patients who were age <20 years, >80 years, pregnant, breastfeeding or severe liver or kidney failure were excluded. 53 out of 73 newly diagnosed patients have signed the informed consent to participate in the study. Completed testing data was collected on 40 patients. All of the patients were randomized into either the intervention or the control groups. For the intervention group, every patient was provided with 500 kcal nutrient supplements per day during a 2-month period of radiotherapy. In contrast, there were no nutrient intervention for the control group.

Results
The immediate effects of nutrition intervention, such as calorie and protein intakes were obviously close to the suggested value (p<0.05). The intervention group was better than control on diet. Control group was significantly reduced on red blood count (×106/mm3), hemoglobin (g/dl), Hct (%), lymphocyte (%), total lymphocyte count (×103/mm3) before and after the testing period (p<0.05). In contrast, there were only white blood cells, lymphocyte (%) and total lymphocyte count (×103/mm3) had been reduced significantly for intervention. The reducing effects were not significantly different between the intervention and the control group. Serum albumin was reduced in both groups, but there is still no significant difference in intergroup comparisons. Significant difference in weight loss was observed at the 4th week of study (p<0.05). The most obviously effect was appeared on final week. There were 4.6±2.4 kg and 2.6±2.4 kg (p<0.05) of weight loss in the control and the intervention group, respectively. This implied that the nutrition intervention could slow down the weight loss of intervention group. The analysis of weight loss percentage also exhibited the same trend and showed a significant difference, which was 2.9% vs. 1.3% for intervention and control groups on week 4 (p<0.05), respectively. The most distinct effect was occurred on final week. There were 6.9±3.2 % and 4.1±4.0 % of weight loss (p<0.05) for control and intervention group, respectively. The results patient generated subjective global assessment (PGSGA) showed that higher score was observed in longer time period of therapy. The intervention group was stable after 3-4 weeks; while the control group was followed an increasing trend. The score comparison on week 6 and final week had a significant difference (p<0.05). In addition to weight loss of cancer patient, body composition is a more concerned issue. All the fat, water content and fat free mass showed a reducing trend. Although, the reducing amounts were not significant between two groups, they were reduced more in control. These results indicated that intervention group could keep the body composition more stable than control. It had been shown some benefits described below. The treatment interruption rate, defined as a 5-day interruption had been improved, which was 15 % vs. 45 % for intervention and control groups, respectively; Interruption group had superior finishing rate of 100%, In contrast, there was only 86% for control.
Conclusions
It is suggested that adequate nutrition support during radiotherapy can decrease impact of side effects, minimize weight loss, and improve quality of life (QoL), decrease radiotherapy interruption rate and increase finishing rate and help patients to recover from the radiotherapy more quickly.

並列關鍵字

head and neck cancer ； radiotherapy ； nutrition status ； malnutrition ； dietary counseling ； oral nutrition supplements ； side effect： quality of life

參考文獻

12.中華民國99年癌症登記報告。中華民國102年2月出版。行政院衛生署國民健康局編印。

5.Laviano A, Renvyle T, Yang Z. From laboratory to bedside- new strategies in the treatment of malnutrition in cancer patients.Nutrition 1996; 12: 112-122.

6.van Bokhorst-de van der Schueren MA, van Leeuwen PA, Sauerwein HP, Kuik DJ, Snow GB, Quak JJ. Assessment of malnutrition parameters in head and neck cancer and their relation to postoperative complications. Head neck 1997; 19: 419-425.

7.Paccagnella, A., Morello, M., Da Mosto, M. C., Baruffi, C., Marcon, M. L., Gava, A., et al. Early nutritional intervention improves treatment tolerance and outcomes in head and neck cancer patients undergoing concurrent chemoradiotherapy. Support Care Cancer 2010; 18, 837-845.

8.EA Isenring, S Capra, JD Bauer. Nutrition intervention is beneficial in oncology outpatients receiving radiotherapy to the gastrointestinal or head and neck area. British Journal of Cancer .2004; 91: 447 – 452.