Bakitas Marie A, Tosteson Tor D, Li Zhigang, Lyons Kathleen D, Hull Jay G, Li Zhongze, Dionne-Odom J Nicholas, Frost Jennifer, Dragnev Konstantin H, Hegel Mark T, Azuero Andres, Ahles Tim A
Marie A. Bakitas, J. Nicholas Dionne-Odom, and Andres Azuero, University of Alabama at Birmingham, Birmingham, AL; Marie A. Bakitas, Jennifer Frost, and Konstantin H. Dragnev, Dartmouth-Hitchcock Medical Center; Zhongze Li, Norris Cotton Cancer Center, Lebanon; Tor D. Tosteson, Kathleen D. Lyons, and Mark T. Hegel, Geisel School of Medicine at Dartmouth; Zhigang Li and Jay G. Hull, Dartmouth College, Hanover, NH; and Tim A. Ahles, Memorial Sloan-Kettering Cancer Center, New York, NY.
J Clin Oncol. 2015 May 1;33(13):1438-45. doi: 10.1200/JCO.2014.58.6362. Epub 2015 Mar 23.
Randomized controlled trials have supported integrated oncology and palliative care (PC); however, optimal timing has not been evaluated. We investigated the effect of early versus delayed PC on quality of life (QOL), symptom impact, mood, 1-year survival, and resource use.
Between October 2010 and March 2013, 207 patients with advanced cancer at a National Cancer Institute cancer center, a Veterans Affairs Medical Center, and community outreach clinics were randomly assigned to receive an in-person PC consultation, structured PC telehealth nurse coaching sessions (once per week for six sessions), and monthly follow-up either early after enrollment or 3 months later. Outcomes were QOL, symptom impact, mood, 1-year survival, and resource use (hospital/intensive care unit days, emergency room visits, chemotherapy in last 14 days, and death location).
Overall patient-reported outcomes were not statistically significant after enrollment (QOL, P = .34; symptom impact, P = .09; mood, P = .33) or before death (QOL, P = .73; symptom impact, P = .30; mood, P = .82). Kaplan-Meier 1-year survival rates were 63% in the early group and 48% in the delayed group (difference, 15%; P = .038). Relative rates of early to delayed decedents' resource use were similar for hospital days (0.73; 95% CI, 0.41 to 1.27; P = .26), intensive care unit days (0.68; 95% CI, 0.23 to 2.02; P = .49), emergency room visits (0.73; 95% CI, 0.45 to 1.19; P = .21), chemotherapy in last 14 days (1.57; 95% CI, 0.37 to 6.7; P = .27), and home death (27 [54%] v 28 [47%]; P = .60).
Early-entry participants' patient-reported outcomes and resource use were not statistically different; however, their survival 1-year after enrollment was improved compared with those who began 3 months later. Understanding the complex mechanisms whereby PC may improve survival remains an important research priority.
随机对照试验支持肿瘤综合治疗与姑息治疗（PC）相结合；然而，最佳时机尚未得到评估。我们研究了早期与延迟PC对生活质量（QOL）、症状影响、情绪、1年生存率和资源使用的影响。
2010年10月至2013年3月期间，在一家国立癌症研究所癌症中心、一家退伍军人事务医疗中心和社区外展诊所的207例晚期癌症患者被随机分配接受面对面的PC咨询、结构化PC远程健康护士指导课程（每周一次，共六次），以及在入组后早期或3个月后进行每月随访。结局指标为QOL、症状影响、情绪、1年生存率和资源使用（住院/重症监护病房天数、急诊就诊次数、过去14天内的化疗情况以及死亡地点）。
总体而言，患者报告的结局在入组后（QOL，P = 0.34；症状影响，P = 0.09；情绪，P = 0.33）或死亡前（QOL，P = 0.73；症状影响，P = 0.30；情绪，P = 0.82）无统计学显著差异。早期组的Kaplan-Meier 1年生存率为63%，延迟组为48%（差异为15%；P = 0.038）。早期与延迟死亡患者的资源使用相对率在住院天数（0.73；95%CI，0.41至1.27；P = 0.26）、重症监护病房天数（0.68；95%CI，0.23至2.02；P = 0.49）、急诊就诊次数（0.73；95%CI，0.45至1.19；P = 0.21）、过去14天内的化疗情况（1.57；95%CI，0.37至6.7；P = 0.27）以及在家中死亡情况（27[54%]对28[47%]；P = 0.60）方面相似。
早期入组参与者的患者报告结局和资源使用无统计学差异；然而，与3个月后开始治疗的患者相比，他们入组后1年的生存率有所提高。了解PC可能改善生存的复杂机制仍然是一个重要的研究重点。
