Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.
Cancer Med. 2022 Apr;11(8):1869-1878. doi: 10.1002/cam4.4565. Epub 2022 Feb 9.
Early palliative care (EPC) improves the quality of life but may not be feasible for all patients with advanced cancer. Symptom screening has been suggested to triage patients for EPC, but scant evidence exists for this practice.
We conducted a subgroup analysis of a cluster-randomized controlled trial of EPC vs. standard oncology care according to patients' baseline symptom scores (high [>23] vs. low [≤23] Edmonton Symptom Assessment System Distress Score [ESAS SDS]). A linear mixed-effects model was used to account for correlation within clusters, adjusting for the baseline outcome score and all covariates in the original trial.
Among the 461 participants, baseline symptom scores were high in 229 patients (127 intervention, 102 control) and low in 232 (101 intervention and 131 control). Among those with high baseline symptoms, there was improved quality of life in the EPC arm compared to controls at 4 months (adjusted difference in primary outcome of FACIT-Sp change score [95% CI], 8.7 [2.8 to 14.5], p = 0.01; adjusted difference in QUAL-E, 4.2 [0.9-7.5], p = 0.02); there was also improved satisfaction with care (6.9 [3.8-9.9], p = 0.001) and clinician-patient interactions (-1.7 [-3.4 to -0.1], p = 0.04), but no significant difference in ESAS SDS (-5.6 [-12.7 to 1.4], p = 0.11). In the low baseline symptom group, there were no significant differences between arms for any outcomes.
EPC improved quality of life, satisfaction with care, and clinician-patient interactions only in those with high baseline symptoms. Symptom severity may be an appropriate criterion to trigger early referrals to palliative care.
早期姑息治疗（EPC）可提高生活质量，但对所有晚期癌症患者可能并不适用。有人建议通过症状筛查对患者进行 EPC 分诊，但这种做法的证据很少。
我们根据患者的基线症状评分（高[>23]与低[≤23]埃德蒙顿症状评估系统困扰评分[ESAS SDS]），对 EPC 与标准肿瘤学治疗的随机对照试验进行了亚组分析。采用线性混合效应模型来解释组内相关性，调整了基线结局评分和原始试验中的所有协变量。
在 461 名参与者中，229 名（127 例干预组，102 例对照组）患者基线症状评分较高，232 名（101 例干预组，131 例对照组）患者基线症状评分较低。在基线症状较高的患者中，EPC 组的生活质量较对照组在 4 个月时得到改善（主要结局的 FACIT-Sp 评分变化[95%CI]，8.7[2.8 至 14.5]，p=0.01；QUAL-E 评分，4.2[0.9 至 7.5]，p=0.02）；患者对护理的满意度（6.9[3.8 至 9.9]，p=0.001）和医患互动（-1.7[-3.4 至 -0.1]，p=0.04）也有所改善，但 ESAS SDS 评分无显著差异（-5.6[-12.7 至 1.4]，p=0.11）。在基线症状较低的患者中，两组在任何结局上均无显著差异。
EPC 仅在基线症状较高的患者中提高了生活质量、对护理的满意度和医患互动。症状严重程度可能是触发对姑息治疗的早期转介的适当标准。
