探討進行改良型乳房切除手術的乳癌病人療效與醫療資源利用

Therapeutic Effect and Medical Resource Utilization of Modified Radical Mastectomy for Breast Cancer Patients

林維峰(Wei-Feng Lin)

指導教授 ： 張肇松

高雄醫學大學/健康科學院/醫務管理學研究所/碩士(2011年)

https://doi.org/10.6832/KMU.2011.00031

摘要

研究背景與目的
根據行政院衛生署統計，乳癌發生人數從1999-2007年4,405人上升至7,502人，發生率從每10萬人40人上升至53.1人，死亡人數從2001-2009年每10萬人1,241人上升至1,588人，在首次療程裡手術有90.7％；放射治療有36.1％；化學治療有67.4％。所以本研究在療效方面，探討在不同治療方式之下，分析長期整體存活率，在醫療資源利用方面，探討治療方式對於門診與住院期間醫療資源利用，所以本研究針對不同的治療方式對於乳癌病人療效與醫療資源利用的影響與相關因素。

研究方法
本研究為一縱貫性研究，採用次級資料進行分析，並利用事後回溯法進行研究，以1999年至2008年原發性乳癌與進行改良型乳房切除術病人為對象，篩選至少存活一年以上且有後續之追蹤紀錄，分成治療方式：改良型乳房切除術、+CT、+RT、+CT+RT。以SPSS 14.0進行統計分析，並利用χ2-test、T-test、One-way ANOVA、Multiple regression analysis、Kaplan-Meier analysis、Multiple Cox regression進行資料分析與驗證假說。

研究結果
病人特性與醫院特性在治療方式對於總費用的影響，在年齡變項，≦45歲相較於≧61歲總費用高出35,423元，46-60歲相較於≧61歲總費用高出35,827元；在CCI變項，≧1相較於0總費用高出62,077元；在醫院地區變項，台北縣市相較於南東部與離島總費用低38,956元，北部相較於南東部與離島總費用低38,442元；在治療方式變項，+CT相較於改良型乳房切除術總費用高出136,519元，+RT相較於改良型乳房切除術總費用高出173,959元，+CT+RT相較於改良型乳房切除術總費用高出381,834元。
病人特性與醫院特性在治療方式對於死亡風險的影響，在年齡變項未達到統計上的顯著差異；在CCI變項，≧1相較於0死亡風險為1.71倍；在醫院權屬變項未達到統計上的顯著差異；在醫院地區變項，台北縣市相較於南東部與離島死亡風險為0.68倍，北部、中部相較於南東部與離島未達到統計上的顯著差異；在治療方式變項，+CT相較於改良型乳房切除術死亡風險為2.59倍，+RT相較於改良型乳房切除術死亡風險為6.04倍，+CT+RT相較於改良型乳房切除術死亡風險為7.05倍。

結論與建議
在醫療資源利用方面，以<61歲、CCI分數以≧1、私立醫院、改良型乳房切除術後有輔助性治療有較高的醫療資源利用。在療效方面年齡、醫院權屬對於死亡風險並無差異；台北縣市有較低的死亡風險；CCI分數≧1、改良型乳房切除術術後有輔助性治療有較高的死亡風險。選擇乳癌治療方式的基本依據為病人本身條件，然而本研究發現改良型乳房切除術的術後輔助性治療，會造成病人療效與醫療資源利用之差異，將此結論提供給醫療院所，討論其行為決策之原則。另外，本研究發現合併症為顯著影響療效與醫療資源利用之因子，因此建議醫療院所應於治療前評估，針對重大影響療效之合併症進行個案篩選，並透過有效的病人照護與手術管理，注意病人合併症所造成的影響，將有助於提高乳癌療效與控管醫療資源。

關鍵字

乳癌 ； 改良型乳房切除術 ； 輔助性治療 ； 醫療資源利用 ； 療效

並列摘要

Background and Objective
According to statistics of the Department of Health, the number of breast cancer from 4,405 to 7,502 in 1999-2007, rate from 40 per 100,000 people increased 53.1, the number of deaths per 100,000 from 1,241 to 1,588 in 2001-2009. First course in surgery is 90.7%; radiotherapy is 36.1%; chemical therapy is 67.4%. So the therapeutic effect in this study, explore the different treatment under the analysis of long-term overall survival, the other point is treatment for outpatient and hospital medical resource utilization, therefore, this study explore different treatment methods for breast cancer therapeutic effect, medical resource utilization and related factors.

Methods
This study is a longitudinal study, use secondary data for primary breast cancer with modified radical mastectomy patients as objects that screening and have at least one year survival follow-up of the track record in 1999-2008. The treatment methods: modified radical mastectomy, +CT, +RT, +CT+RT. The SPSS 14.0 statistic software, and use χ2-test, T-test, One-way ANOVA, Multiple regression analysis, Kaplan-Meier analysis, Multiple Cox regression for data analysis and validation hypothesis.

Results
Patient and hospital characteristics in the total expenses of treatment for the effects in the age variables, ≦45 years compared to ≧61 years the total expenses were higher than $35,423, 46-60 years compared to ≧61-years the total expenses were higher than $35,827; in the CCI variabless, ≧1 compared to 0 the total expenses were higher than $62,077; in the hospital district variables, Taipei City and County compared to Eastern, Southern and islands the total expenses were lower than $38,956, the Northern compared to Eastern, Southern and islands the total expenses were lower than $38,442; in the treatment methods variables, +CT compared to modified radical mastectomy the total expenses are than $136,519, +RT compared to modified radical mastectomy the total expenses are than $173,959, +CT+RT compared to modified radical mastectomy the total expenses are than $381,834.
Patient and hospital characteristics in the treatment for the risk of mortality, the age variables were not significance; in the CCI variables, ≧1 compared to 0 the risk of death was 1.71; in hospital ownership variables were not significance; in the hospital district variables, Taipei City and County compared to Eastern, Southern and islands the risk of death was 0.68, the Northern compared to Eastern, Southern and island was no significance; in the treatment methods variables, +CT compared to modified radical mastectomy the risk of death was 2.59, +RT compared to modified radical mastectomy the risk of death was 6.04, +CT+RT compared to modified radical mastectomy risk of death was 7.05.

Conclusion and suggestion
Medical resource utilization, <61 years, CCI ≧1, private hospitals, modified radical mastectomy with adjuvant therapy have higher medical resource utilization. The therapeutic effect, age, hospital ownership for the risk of death was not significance; Taipei City and County have a lower risk of death; CCI ≧1, modified radical mastectomy with adjuvant therapy have a higher risk of death. Choose breast cancer treatment based on the basic conditions for the patients themselves, but this study found that modified radical mastectomy with adjuvant therapy, result in the patient treatment and medical resource utilization differences, this conclusion available to medical institutions, to discuss its behavioral decision-making principles. In addition, the study found a significant impact on the therapeutic effect and complications of medical resource utilization of the factors, it is suggested hospitals should be assessed before treatment, a significant impact on the efficacy of complications for a case screening, and through effective patient care and surgical management, note that the impact of patient complications will help to improve breast cancer treatment and control of medical resource.

並列關鍵字

breast cancer ； modified radical mastectomy ； adjuvant therapy ； medical resource utilization ； therapeutic effect

參考文獻

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