Gupta Sumit, Li Qing, Kassam Alisha, Rapoport Adam, Widger Kimberley, Chalifour Karine, Baxter Nancy N, Nathan Paul C, Coburn Natalie G, Sutradhar Rinku
Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada.
Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
JAMA Netw Open. 2023 Oct 2;6(10):e2338699. doi: 10.1001/jamanetworkopen.2023.38699.
Adolescents and young adults (AYAs) with cancer experience substantial symptom burden. Specialty palliative care (SPC) is recommended but often not involved or involved late.
To determine whether patient-reported symptom severity was associated with subsequent SPC involvement and whether SPC was associated with symptom improvement in AYAs with cancer.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study comprised AYAs (aged 15-29 years) with primary cancer diagnosed between January 1, 2010, and June 30, 2018, in Ontario, Canada. Data, including self-reported Edmonton Symptom Assessment System (ESAS) scores, were obtained from health care databases. Specialty palliative care was identified through billing codes and validated algorithms. Final data analysis was performed on April 4, 2023.
Associations of ESAS scores with subsequent SPC involvement were determined. A difference-in-differences approach was used for patients who died within 5 years of their cancer diagnosis. Case patients (SPC predeath, index date equals first SPC service) were matched 1:1 to control patients (no SPC at equivalent time before death). The study examined whether the difference between 90-day postindex and preindex mean ESAS scores was itself different between case and control patients.
This study included 5435 AYAs with cancer, with a median follow-up of 5.1 (IQR, 2.5-7.9) years for analyses of general palliative care. Their median age at cancer diagnosis was 25 (IQR, 22-27) years, and more than half were male (2809 [51.7%]). For all symptoms, moderate and severe ESAS scores were associated with an increased likelihood of SPC involvement compared with mild scores. The greatest magnitude of association was seen for pain scores (hazard ratio for severe vs mild, 7.7 [95% CI, 5.8-10.2]; P < .001). A total of 721 AYAs (13.3%) died within 5 years of diagnosis, and 612 of these patients (84.9%) had received SPC before death. Among 202 case-control pairs, SPC involvement was associated with improved pain trajectories (mean scores improved from 3.41 to 3.07 in case patients and worsened from 1.86 to 2.16 in control patients; P = .003). Other symptom trajectories were not affected.
In this cohort study of AYAs with cancer, those reporting moderate or severe symptoms through a screening program were more likely to subsequently receive SPC. These findings suggest that SPC was associated with a subsequent decrease in pain severity but did not affect other symptoms. New interventions targeting other symptoms during treatment and particularly at the end of life are needed.
患有癌症的青少年和青年（AYA）承受着巨大的症状负担。推荐采用专科姑息治疗（SPC），但往往未被纳入或介入较晚。
确定患者报告的症状严重程度是否与随后的SPC介入相关，以及SPC是否与患有癌症的AYA的症状改善相关。
设计、设置和参与者：这项队列研究纳入了2010年1月1日至2018年6月30日期间在加拿大安大略省被诊断为原发性癌症的AYA（年龄在15 - 29岁之间）。数据，包括自我报告的埃德蒙顿症状评估系统（ESAS）评分，来自医疗保健数据库。通过计费代码和经过验证的算法确定专科姑息治疗。最终数据分析于2023年4月4日进行。
确定ESAS评分与随后的SPC介入之间的关联。对于在癌症诊断后5年内死亡的患者，采用差异-in-差异方法。病例患者（死亡前接受SPC，索引日期等于首次SPC服务）与对照患者（在死亡前同等时间未接受SPC）按1:1匹配。该研究检查了索引后90天与索引前平均ESAS评分之间的差异在病例患者和对照患者之间是否本身存在差异。
本研究包括5435名患有癌症的AYA，分析一般姑息治疗的中位随访时间为5.1（四分位间距，2.5 - 7.9）年。他们癌症诊断时的中位年龄为25（四分位间距，22 - 27）岁，超过一半为男性（2809 [51.7%]）。对于所有症状，与轻度评分相比，中度和重度ESAS评分与SPC介入的可能性增加相关。疼痛评分的关联程度最大（重度与轻度的风险比，7.7 [95%置信区间，5.8 - 10.2]；P <.001）。共有721名AYA（13.3%）在诊断后5年内死亡，其中612名患者（84.9%）在死亡前接受了SPC。在202对病例对照中，SPC介入与疼痛轨迹改善相关（病例患者的平均评分从3.41改善到3.07，对照患者从1.86恶化到2.16；P =.003）。其他症状轨迹未受影响。
在这项针对患有癌症的AYA的队列研究中，通过筛查计划报告中度或重度症状的患者随后更有可能接受SPC。这些发现表明，SPC与随后疼痛严重程度的降低相关，但不影响其他症状。需要在治疗期间，特别是在生命末期针对其他症状的新干预措施。
