乳癌術後存活病患復發之心理社會因子探討

Psychosocial factors associated with the recurrence of breast cancer survivors after treatments

鄭雅心(Ya-Hsin Cheng)

指導教授 ： 張永源

高雄醫學大學/健康科學院/公共衛生學研究所/碩士(2012年)

摘要

目的：主要探討乳癌存活病患在控制生物因子與遺傳因子的影響後，心理社會因子在術後復發所扮演的角色。

方法：以1996年1月至2010年12月經醫師診斷確定為乳癌的病人做為研究對象，共計219位乳癌婦女納入此研究，利用結構式問卷的方式蒐集病人的基本資料與心理社會因子，並採用回溯性個案對照研究設計法（retrospective case-control studies），若於門診追蹤期間發現有復發情形的病患歸類為個案組，未曾復發之病患納入對照組。第二階段利用半結構式的訪談大綱對乳癌復發患者進行深度訪談，以收集關於受訪者復發前較為完整的心理狀態資訊。以獨立樣本T檢定及卡方檢定來比較個案組與對照組的基本資料以及心理社會因子之間的差異，並以Kaplan-Meier統計出五年及十年復發率，在多變量的部分使用Cox廻歸模式存活分析來探討在控制其他生物與遺傳因子後，心理社會因子對於復發所扮演的角色。

結果：本研究以219位乳癌病患進行分析，追蹤期間有31位發生復發情形，復發時間中位數為36個月，以Kaplan-Meier統計出五年及十年復發率，分別為13.1%與21%，而患者罹患乳癌的平均年齡為48.17歲。Cox廻歸模式存活分析的結果顯示在控制其他變項後，年齡每多一歲，則會下降4%的復發風險（HR=0.96；95%C.I. = 0.91~1.00），而沒有接受賀爾蒙治療患者的復發風險是有接受賀爾蒙治療患者的2.4倍（HR=2.4；95%C.I. = 0.20~0.87）。此外四項心理社會因子（憂鬱、焦慮、癌症特定困擾、與情緒表達狀態）皆無達到統計學上顯著差異。

結論：雖然本研究各項心理社會因子在統計分析上皆無達到顯著差異，但透過深度訪談可以發現在乳癌未復發前，幾乎所有受訪者皆不善於表達負面情緒，且無適當的因應方式或抒壓管道，大部分的患者是在復發以後，才慢慢學會如何抒發內心情緒，且本研究從訪談過程中發現，除了乳癌本身帶給患者的心理影響外，外在壓力的影響也是一重要因素，值得做更進一步的分析探討。

關鍵字

乳癌復發 ； 心理社會因素 ； 存活分析 ； Cox比例危害模式

並列摘要

Objective：The purpose of this study was to assess the psychosocial factors significantly associated with the recurrence of breast cancer survivors after finish surgical treatment and adjuvant therapy.

Methods：A retrospective case-control study is designed, and the patients diagnosed as breast cancer were reviewed retrospectively from Dec. 31, 2010 to Jan. 01, 1996. The study sample consisted of 219 breast cancer patients, and 31 case had recurrence in follow-up at OPD（out-patient）. All of the data concerned with biological factors, socio-demographic characteristics, and psychosocial factors had been extracted from the structured questionnaire. Then semi-structured interview was used to gather more complete mental status information before patients were recurrence of the case group. We used two sample t-test and Chi-square test to compare the difference between the case group and control group. Kaplan-Meier method was used to estimate 5-years recurrent rate. Cox Proportional Hazards Model was used to explore the role of psychosocial factors for recurrence after controlling for biological and genetic factors.

Results：219 breast cancer patients were analyzed with a median age of 48. The median recurrent time was 36 months. 5-years and 10-years recurrent rate were 13.1% and 21%. According to Cox Proportional Hazards Model we found, young (HR=0.96；95%C.I. =0.91~1.00), and none acceptance of hormone therapy (HR=2.4；95%C.I. =0.20~0.87) were significantly predicted breast cancer recurrence. Psychosocial factors, including depression, anxiety, impact of events, and emotional expressivity were not found significantly as the predictors of recurrence.

Conclusion：The psychosocial factors were not significantly different between case group and control group in this study. Using in-depth interview technique, we found four of the five patients were not expressing negative emotions, and no appropriate ways to coping with those emotions. They understand how to express negative emotions after recurrence. In addition, we found that the effect of stress was an important factor association with breast cancer recurrence.

並列關鍵字

Breast Cancer Recurrence ； Psychosocial Factors ； Survival Analysis ； Cox Proportional Hazards Model

參考文獻

英文參考文獻

AJCC. (2010). What is cancer staging? , from http://www.cancerstaging.org/mission/whatis.html

Alexander, P. J., Dinesh, N., & Vidyasagar, M. S. (1993). Psychiatric morbidity among cancer patients and its relationship with awareness of illness and expectations about treatment outcome. Acta Oncol, 32(6), 623-626.

American Cancer Society. (2011a). How is breast cancer staged? , from http://www.cancer.org/Cancer/BreastCancer/DetailedGuide/breast-cancer-staging

American Cancer Society. (2011b). When Cancer Comes Back: Cancer Recurrence from http://www.cancer.org/Treatment/SurvivorshipDuringandAfterTreatment/UnderstandingRecurrence/WhenYourCancerComesBack/when-cancer-comes-back-what-is-recurrence