放射線治療之癌症病人的症狀困擾、心理痛苦、身體組成及失志變化： 縱貫性研究

Change of Symptom Distress, Psychological Distress, Body Composition and Demoralization in Cancer Patients with Radiotherapy: A Longitudinal Study

唐佩玲(Pei-Ling Tang)

指導教授 ： 周汎澔

高雄醫學大學/護理學院/護理學系博士班/博士(2017年)

摘要

有關癌症治療對於病人之身體、心理、社會、靈性層面影響甚大，其變化是亟待了解的重要議題。本研究以「全人」方向來考慮，探討個人疾病、症狀困擾、心理痛苦、身體組成與失志變化情形。以了解癌症病人在放射線治療階段至治療後3個月之癌症治療方式在不同階段對頭頸部、胸部及乳房、腹部及骨盆腔三種部位癌症病人造成的影響，發掘並察覺病人失志的影響因子。
本研究採縱貫性研究設計，於南部地區某醫學中心放射腫瘤治療部進行資料收集，共收案101人。收案條件為經醫師確立初診斷為惡性腫瘤，需作癌症放射線治療的病人；年齡18歲以上、知病情、能使用國台語溝通、意識清楚且能以文字填答問卷者；排除條件包括：病人此次治療目的為姑息性放射線治療、經醫師診斷為癌症復發治療的病人及病人無法站立及體力狀況無法填答者。採無記名、自填式填寫方式，研究工具包括社會人口學與疾病治療、症狀困擾量表、心理痛苦溫度計量表、中文版失志量表及身體組成分析儀In Body3.0 之生理測量；資料收集時間點(放射線治療前、治療第二週、治療第四週、治療結束、結束第一個月、結束第三個月) 。統計分析方法包含頻率、百分比、平均值、標準差等描述性統計之外，並以「廣義估計方程式」（Generalized Estimating Equation, GEE）進行主要研究變項間的相關性，經由調整其他相關變項及重複施測時間的影響因素來校正各變項間相依性，探討癌症病人放射治療三個月期間各階段之「症狀困擾」、「心理痛苦」、「身體組成」與「失志」的相關性。
控制共變項後研究發現：
1.頭頸部癌症病人症狀困擾在治療第二週，平均上升7.59 (β = 7.59, p ＜.0001)，達到顯著的差異。有手術及化學治療者顯著影響胸部及乳房癌症病人的症狀困擾( β = -4.58 , p = .0017; β = 2.57, p = .0333 )。腹部及骨盆腔癌症第4期的病人，症狀困擾顯著高於其他期別( β = 16.28, p < .0001)。
2.經濟的來源來自於他人及第1期的頭頸部病人之心理痛苦較高( β = -0.93, p = .0392; β = -1.22, p = .0048)。胸部及乳房癌症病人的心理痛苦，也是第1期的病人心理痛苦較高(β = -1.23, p = .0006)，在結束第一個月最低( β = -1.09, p = .0309)。腹部及骨盆腔癌症的病人在治療期間心理痛苦都比治療前降低，雖然在第六個時間點(治療結束第三個月)有上揚的變化，但未達到顯著差異。
3.身體質量指數在頭頸部癌症病人，除了在治療結束第一個月( β = -0.94, p = .0384)，顯著的下降外，在其他時間點，並無顯著的改變。在胸部及乳房癌症病人，身體質量指數在治療第四週及治療結束這兩個時間點有下降的情形 ( β = -0.50, p = .0489; β = -2.10, p = .0077)；在腹部及骨盆腔癌症的病人呈現治療結束第三個月這個時間點顯著的上升( β = 1.99, p = .0423)；男性、年齡>50歲及期別等這些因素都有影響。
4.頭頸部癌症的病人教育程度為高中（職）及無職業者之失志程度有顯著的較高( β = 6.42, p = . 0406; β = 5.70, p = .0459)；胸部及乳房癌症病人在治療第二週時間點，失志達到顯著的下降( β = -2.93, p = .0418)。腹部及骨盆腔癌症病人之期別、手術、化學治療失志程度有不同的變化。
本研究發現，我國癌症病人有嚴重的高失志，且失志在不同癌症及時間點有不同差異變化。症狀困擾及心理痛苦為所有癌症病人的失志的顯著因子；身體組成分析結果，為胸部及乳房癌症病人失志的顯著因子。因應癌症病人在不同時間點的變化，病人的健康照護需求也有所不同。由於失志為一個複雜的情緒狀態，可能會有未測量的現象，尤其是時間的軌跡變化因素，因此本研究建議進行更長期的縱貫性資料收集，才能看到失志影響關係之完整樣貌。本研究提供跨專業醫療照護團隊合作在腫瘤臨床心理實務工作的推展上進一步的證據，考慮癌症治療方式在不同階段對病人造成的影響而機動調整，達到最佳團隊合作進而提供病患完整及持續的全人醫療照護。

關鍵字

症狀困擾 ； 心理痛苦 ； 身體組成 ； 失志 ； 癌症

並列摘要

Cancer treatments have profound implications for the physical, mental, social, and spiritual wellbeing of patients with cancer. This issue has been receiving widespread attention. Thus, this study presents a holistic view of (1) the changes in the symptom distress, psychological distress, body composition, and demoralization of Taiwanese patients with cancer from the beginning of radiation therapy to three months after the treatment, as well as (2) the influences of the aforementioned changes on patients’ level of demoralization. The result indicated:
1. The symptom distress of patients with head and neck cancer is increased, on average, by 2.20 at Week 2 of treatment, which has reached a significant difference. Surgery and chemotherapy have significant impacts on the symptom distress of patients with chest and breast cancer. The symptom distress of patients with stage 4 abdominal and pelvic cancer is significantly higher than that of those in other stages.
2. The psychological distress of patients whose economic source is from others, and patients with stage 1 head and neck cancer, is higher. For patients with chest and breast cancer, those in stage 1 have higher psychological distress, while those after completing the first month treatment have the lowest psychological distress. The psychological distress of patients with abdominal and pelvic cancer during treatment is lower than that before treatment. Although it is increased at the 6th time point (3 months after the completion of the treatment), the difference does not reach a level of significance, and it is not affected by other factors.
3. The BMI of patients with head and neck cancer does not show significant change, except for a significant decrease in the first month after completing the treatment. For patients with chest and breast cancer, their BMI is decreased slightly at the fourth week and upon the completion of the treatment. The BMI of patients with abdominal and pelvic cancer is significantly increased at the third month after completing the treatment, while the factors affecting the BMI include gender (male), age >50, and disease stage.
4. The level of demoralization of patients with head and neck cancer, whose educational background is high school or vocational school, and who are unemployed, is significantly higher. The level of demoralization of patients with chest and breast cancer is decreased significantly at the second week of treatment. The disease stage, surgery, and chemotherapy have impacts on the level of demoralization of patients with abdominal and pelvic cancer.
Investigating the changes of patients with cancer at various time points of the treatment process enabled this study to identify related factors that affected the patients in the adverse situation of treatment. The findings are as follows. Taiwanese patients with cancer were highly demoralized, and that the extent of their demoralization varied according to the body parts that were affected by the disease and the particular stages of treatment they were in. Second, psychological and symptom distress served as predictors of patient demoralization. Third, the relationship between the demoralization levels and the body composition of patients who were affected in their head, neck, abdomen, and pelvis was nonsignificant. These findings are expected to inform the adjustment of treatment plans for patients with cancer and facilitate providing patients with appropriate healthcare services.

並列關鍵字

Symptom Distress ； Psychological Distress ； Body Composition ； Demoralization ； Cancer

參考文獻

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