NS Nursing Science 2168-5657 Scientific Research Publishing 10.12677/ns.2024.135091 NS-88099 ns2024135_222251300.pdf 医药卫生 乳腺癌患者经济毒性的研究进展 Research Progress of Economic Toxicity in Breast Cancer Patients 2 1 汶玲 3 1 小莉1† 2 1 吉首大学医学院,湖南 张家界 重庆市妇幼保健院,重庆 null 06 05 2024 13 05 642 647 © Copyright 2014 by authors and Scientific Research Publishing Inc. 2014 This work is licensed under the Creative Commons Attribution International License (CC BY). http://creativecommons.org/licenses/by/4.0/

介绍乳腺癌患者经济毒性的概念、评估工具、影响因素、结局及应对措施,旨在为医务人员开展相关的研究提供参考,以帮助乳腺癌患者及家属更好地应对经济问题,减少其经济毒性的发生。 The concept, assessment tools, influencing factors, outcome and countermeasures of economic toxicity in breast cancer patients were introduced in order to provide reference for medical personnel to carry out related research, so as to help breast cancer patients and their families to better cope with economic problems and reduce the occurrence of economic toxicity.

乳腺癌,经济毒性,影响因素,应对措施,综述, Breast Cancer Economic Toxicity Influencing Factors Countermeasures Summarize
摘要

介绍乳腺癌患者经济毒性的概念、评估工具、影响因素、结局及应对措施,旨在为医务人员开展相关的研究提供参考,以帮助乳腺癌患者及家属更好地应对经济问题,减少其经济毒性的发生。

关键词

乳腺癌,经济毒性,影响因素,应对措施,综述

Research Progress of Economic Toxicity in Breast Cancer Patients<sup> </sup>

Huan Li1*, Wenling Xie2#, Xiaoli Wang1†

1Medical School, Jishou University, Zhangjiajie Hunan

2Chongqing Maternal and Child Health Care Hospital, Chongqing

Received: Apr. 18th, 2024; accepted: May 23rd, 2024; published: May 31st, 2024

ABSTRACT

The concept, assessment tools, influencing factors, outcome and countermeasures of economic toxicity in breast cancer patients were introduced in order to provide reference for medical personnel to carry out related research, so as to help breast cancer patients and their families to better cope with economic problems and reduce the occurrence of economic toxicity.

Keywords:Breast Cancer, Economic Toxicity, Influencing Factors, Countermeasures, Summarize

Copyright © 2024 by author(s) and beplay安卓登录

This work is licensed under the Creative Commons Attribution International License (CC BY 4.0).

http://creativecommons.org/licenses/by/4.0/

1. 引言

目前乳腺癌仍居我国女性恶性肿瘤发病首位,据统计2020年全球癌症登记数据中 [ 1 ] ,乳腺癌是全球癌症发病率首位,新发病例约占11.7% (230万例),死亡人数约68.5万例(占6.9%);而中国女性乳腺癌占全球乳腺癌病例数的18.6%,占全球乳腺癌死亡人数的18% [ 2 ] 。随着诊治技术的发展,乳腺癌患者的健康状况虽较比之前有所改善,但治疗产生的相关费用却在与日俱增 [ 3 ] 。据统计,2014年我国乳腺癌患者的医疗费用平均为7527美元,高出了居民平均可支配收入的2倍多 [ 4 ] ,使得乳腺癌患者不仅身体和精神、心理承受癌症带来的痛苦,同时治疗费用也使患者压力巨大 [ 5 ] 。经济毒性(Financial Toxicity, FT)是指患者在治疗期间因经济负担所带来的负面影响,覆盖客观经济负担和主观经济困境,使得生活方式改变、生活质量下降,从而增加患者心理负担,影响疾病治疗效果 [ 6 ] 。有研究发现乳腺癌患者存在经济毒性,约有的约占59.35%~65.7% [ 7 ] [ 8 ] ,高于美国学者OFFODILE等 [ 9 ] 研究。因此,我们需重视乳腺癌患者经济毒性的发生。本文对乳腺癌患者经济毒性的研究进行综述,以期对乳腺癌患者的评估及干预提供理论参考。

2. 概念

“经济毒性”最早在2012年被Bullock等 [ 10 ] 提及,是将癌症相关治疗成本的讨论更加概念化,以便医护人员向患者普及经济毒性相关知识。2023年,Zafar等 [ 6 ] 进一步细化了经济毒性的概念,将医疗支出所造成的心理困扰和生活质量下降归纳为“癌症相关性经济毒性性”(cancer-relatedfinancialtoxicity, FT),他认为治疗导致的经济毒性会影响患者的生存质量,妨碍患者选择最佳的治疗方案和护理 [ 11 ] 。学者况艺等 [ 12 ] 也明确“癌症相关经济毒性”的定义属性为客观经济负担和主观经济困境,因癌症治疗期间的费用增加而收入减少,使患者因面临经济负担,使得主观幸福感和及生活质量下降等,也导致患者的治疗依从性下降,给患者的诊疗与生活带来巨大影响。目前,相关领域的国内外学者对于乳腺癌治疗对患者的经济毒性仍不够重视,未来可作进一步的研究,为今后的评估和干预提供理论基础。

3. 测评工具 3.1. 乳腺癌财务调查量表(breast cancer finances survey, BCFS)

该量表于1994年由Given等 [ 13 ] 改编发表的评估工具,主要用来评估乳腺癌患者财务困难的主要问题,包括42个条目,每个条目均为是非题,回答选择“是”,记1分;回答选择“否”,记0分。每个条目均根据自身情况进行作答,得分越低,经济负担越轻,反之,经济负担越重。其中经济来源、生活改变个条、寻求经济帮助、日常开销及应对措施 [ 13 ] [ 14 ] 等14个条目最能评估乳腺癌患者的经济毒性的严重程度。该量表评估内容较全面,可专门用于乳腺癌患者的评估,但由于量表条目较多,在问卷收集过程可能存在耗时较长等问题。目前该量表只有英文版,尚未被翻译成中文,故应用范围较局限。同时,该量表的信度、效度没有也确切报告,尚缺少多中心大规模临床研究对量表的心理测量特性进行验证 [ 15 ] 。

3.2. 患者报告结局的经济毒性综合评分表(Comprehensive Scores for Financial Toxicity Based on the Patient-Reported Outcome Measures, COST-PROM)

此量表由DeSouza等 [ 16 ] 研制,是第一个评估癌症患者经济困难的工具,于慧会等 [ 17 ] 修订为中文版,包含11个条目,该量表的Cronbach’s α系数为0.889。该量表内部一致性较好适用于多种类型的癌症患者。目前被广泛运用于经济毒性的评估中,有较强的适用性。采用五级评分法(0~4分),分别对应“一点也不”到“非常”,总分范围是0~44分,总分 > 25为没有经济毒性,得分越高,经济毒性越低,反之,得分越低,经济毒性越高。

3.3. 经济毒性分级标准

该量表于2014年由Khera [ 18 ] 提出,并将其经济毒性分为4级,分别为轻度(1级)、中度(2级)、重度(3级)、危及生命或致残(4级)等。该分级标准并已被译为中文版本,医护人员可根据其分级对患者进行早期评估,但目前国内应用较少。目前该分级标准尚未得到广泛应用,是否适合乳腺癌患者经济毒性的评估还有待验证。

3.4. 个人经济健康量表(Personal Financial Wellness scale, PFW)

该量表由Prawitz [ 19 ] 等编制,用于评估不同人群在经济方面的主观感受和处境。此量表包含3个维度,即个人心理社会影响(5个条目)、个人经济来源(2个条目)和生活改变(1个条目)。该量表的Cronbach’s α系数为0.956。每个条目分数范围为1~10分,得分越低,表明经济处境越困难、经济幸福感越低 [ 20 ] ;反之,得分越高,经济处境较低,经济幸福感越高。

4. 影响因素 4.1. 社会人口学因素

乳腺癌患者经济毒性的严重程度与其年龄 [ 20 ] 、居住地 [ 20 ] [ 21 ] [ 22 ] [ 23 ] 、文化程度 [ 8 ] [ 21 ] [ 22 ] 、婚姻状况 [ 8 ] 、工作状况 [ 8 ] 、医保 [ 21 ] [ 22 ] [ 23 ] 、家庭收入水平 [ 8 ] [ 24 ] [ 25 ] 等因素有关。据报道,经济毒性水平受婚姻状况和年龄的影响,由于年轻或未婚女性乳腺癌患者往往缺乏经济支持和家庭帮助,因此会承受更高的经济毒性 [ 25 ] 。而在国外研究表明,在印度和东南亚,很少有患者有保险,大多数患者完全自费,这也使得患者需要承担更高的经济负担 [ 22 ] 。有些患者因家庭居住地或工作单位离医院较远,由此需要负担更多额外的住宿或交通费用,这也使得经济毒性的风险增加 [ 20 ] 。若家庭人均收入不高和经济困难的患者,这也加剧了经济毒性发生的风险 [ 11 ] [ 23 ] 。国内研究发现,当乳腺癌患者社会支持水平较高时,则其经济毒性水平降低 [ 20 ] 。国外研究表明,小于65岁的患者发生经济毒性的风险会增加 [ 26 ] 。而国内研究发现,年轻人的经济毒性程度普遍低于中年人,这可能与中年人需要养育孩子及赡养老年人有关 [ 27 ] 。

4.2. 疾病相关因素

患病时常 [ 8 ] 、疾病分期 [ 28 ] 、恐惧疾病进展 [ 20 ] 等因素均会导致乳腺癌经济毒性的发生。分期越晚,患者面临更高的治疗费用,患者重返工作岗位延长导致收入更少,导致经济毒性更大 [ 28 ] [ 29 ] 。而费用越少,治疗时间越短,出现转移或复发的晚期患者,治疗费用几乎是早期患者的2倍 [ 30 ] 。因此,患者患病的时长、当前所处的疾病分期、患者自身的心理因素等均会对经济毒性产生或多少的影响。

4.3. 社会因素

患者是否购买医疗保险、自我效能、社会支持等也会影响患者的经济压力。研究表明,乳腺癌化疗费用在各种方案中差异很大,患者需自掏腰包承担费用 [ 31 ] 。研究发现,不管是否有医保其死亡率均相近,但发现无医保的患者发生并发症更频繁,从而导致住院时间延长、经济毒性风险增加和术后生活质量更差 [ 11 ] [ 32 ] 。因此,未来需对乳腺癌患者经济毒性的相关影响因素作进一步研究。

5. 结局

经济毒性与生活质量及心理健康状况呈正相关 [ 33 ] ,从而导致患者产生一些不当的应对方式,从而影响患者预后效果 [ 34 ] 。经济毒性的影响甚至在癌症诊断之前就可能出现,这些患者由于缺乏定期的筛查,延迟诊断,导致预后较差。我国学者夏娟等 [ 35 ] 发现,确诊为乳腺癌后1年的患者生活质量下降最主要的影响因素是经济困难。同时,国外学者Ramsey等 [ 36 ] 也指出,申请破产的乳腺癌幸存患者的死亡风险也增加了50%。

6. 应对措施 6.1. 个人层面

患者普遍通过改变原有生活方式、降低依从性来应对经济毒性。通过增加收入、降级消费,减少开支等方式来理性应对。研究指出,7%的患者增加了工作时间以支付与癌症相关的费用,而缓解经济压力最主要的方式是重新回到工作岗位 [ 37 ] 。调整非医疗支出或降低治疗依从性来减少开支也是应对经济毒性的方式之一。研究表明46%的患者因为癌症的治疗费用而降低了平时衣食支出 [ 38 ] 。可见,依从性下降虽然为患者节约成本,但同时也增加了各种不良后果的风险 [ 5 ] 。

6.2. 医院层面

医护人员在乳腺癌的治疗与护理中,在提供优质医疗服务方面、帮助患者减轻经济毒性风险都发挥着重要作用 [ 39 ] [ 40 ] 。医护人员应对经济毒性进行评估,尽早识别其风险,以便做出及时干预。有研究指出,94%的患者认为医生应该跟他们讨论治疗成本,但在实际的临床中只有14%的患者报告称,医生与他们进行了讨论 [ 41 ] [ 42 ] 。学者KAZZI B [ 43 ] 等也研究发现,患者在确诊后的12个月内,与患者积极沟通治疗费用且提供更利于患者的治疗方案可减轻经济负担。因此,建议医护人员应尽早加强普及和实时评估,减轻患者经济负担,减少其经济毒性的发生。也可借助移动医疗服务,通过电话和视频为癌症幸存者提供延续性护理,以减轻经济负担 [ 44 ] 。

7. 小结

乳腺癌诊断后的经济毒性可能即刻发生,也可能有延迟出现。虽有学者开发了经济毒性的评估工具,但未来需根据乳腺癌患者治疗的特异性开发适用于我国文化特色的乳腺癌患者经济毒性评估工具,并确定适合的评估和干预时机。此外,还可以开展纵向及多个中心的研究,深入探讨乳腺癌患者在各个治疗阶段的经济毒性风险,从而来制定干预目标,提供更有效的干预方案,以减轻乳腺癌患者经济负担,降低经济毒性的风险及影响。

基金资助

2023吉首大学研究生科研创新项目(Jdy23064)。

文章引用

李 欢,谢汶玲,王小莉1†. 乳腺癌患者经济毒性的研究进展Research Progress of Economic Toxicity in Breast Cancer Patients[J]. 护理学, 2024, 13(05): 642-647. https://doi.org/10.12677/ns.2024.135091

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