Joseph A. Greer, Jamie M. Jacobs, Areej El-Jawahri, Ryan D. Nipp, Emily R. Gallagher, Elyse R. Park, Alona Muzikansky, Juliet C. Jacobsen, Vicki A. Jackson, and Jennifer S. Temel, Massachusetts General Hospital and Harvard Medical School, Boston, MA; and William F. Pirl, Sylvester Comprehensive Cancer Center and University of Miami, Miami, FL.
J Clin Oncol. 2018 Jan 1;36(1):53-60. doi: 10.1200/JCO.2017.73.7221. Epub 2017 Nov 15.
Purpose The early integration of oncology and palliative care (EIPC) improves quality of life (QOL) and mood for patients with advanced cancer. However, the mechanisms by which EIPC benefits these outcomes remain unclear. We therefore examined whether EIPC improved patients' coping strategies and if changes in coping accounted for intervention effects on QOL and depressive symptoms. Patients and Methods For this secondary analysis of an EIPC trial, we examined data from 350 patients with newly diagnosed incurable lung or GI cancer. Participants completed assessments of QOL (Functional Assessment of Cancer Therapy-General), depressive symptoms (Patient Health Questionnaire-9), and coping (Brief COPE) at baseline and 24 weeks. We used linear regression to test intervention effects on use of coping strategies and mediation regression models with bias-corrected bootstrapping to examine whether improvements in coping mediated the effects of early palliative care on patient-reported outcomes. Results Compared with usual oncology care, EIPC significantly increased patient use of approach-oriented coping strategies ( B = 1.09; SE = 0.44; P = .01) and slightly reduced use of avoidant strategies ( B = -0.44; SE = 0.23; P = .06) from baseline to 24 weeks. Also, the increased use of approach-oriented coping and reduction in avoidant coping were associated with higher QOL and lower depressive symptoms at 24 weeks. The positive changes in approach-oriented coping, but not avoidant coping, significantly mediated the effects of EIPC on QOL (indirect effect, 1.27; 95% CI, 0.33 to 2.86) and depressive symptoms (indirect effect, -0.39; 95% CI, -0.87 to -0.08). Conclusion Patients with incurable cancer who received EIPC showed increased use of approach-oriented coping, which was associated with higher QOL and reduced depressive symptoms. Palliative care may improve these outcomes by providing patients with the skills to cope effectively with life-threatening illness.
肿瘤学和姑息治疗的早期整合（EIPC）可改善晚期癌症患者的生活质量（QOL）和情绪。然而，EIPC 带来这些益处的机制尚不清楚。因此，我们研究了 EIPC 是否改善了患者的应对策略，以及应对策略的变化是否解释了干预对 QOL 和抑郁症状的影响。
这是一项 EIPC 试验的二次分析，我们研究了 350 名新诊断为不可治愈的肺癌或胃肠道癌患者的数据。参与者在基线和 24 周时完成了 QOL（癌症治疗功能评估-一般）、抑郁症状（患者健康问卷-9）和应对（简要应对方式问卷）的评估。我们使用线性回归检验干预对应对策略的影响，并用带有偏置校正自举的中介回归模型检验应对策略的改善是否介导了早期姑息治疗对患者报告结果的影响。
与常规肿瘤学治疗相比，EIPC 显著增加了患者采用积极应对策略的比例（ B = 1.09；SE = 0.44；P =.01），并略微减少了回避策略的使用（ B = -0.44；SE = 0.23；P =.06）。此外，从基线到 24 周，采用积极应对策略的比例增加和回避策略减少与更高的 QOL 和更低的抑郁症状相关。EIPC 对 QOL（间接效应，1.27；95%CI，0.33 至 2.86）和抑郁症状（间接效应，-0.39；95%CI，-0.87 至 -0.08）的影响与积极应对策略的变化显著相关，但与回避策略的变化无关。
接受 EIPC 的不可治愈癌症患者采用了更多的积极应对策略，这与更高的 QOL 和更低的抑郁症状相关。姑息治疗可能通过为患者提供应对危及生命疾病的技能来改善这些结果。
