頭頸癌病人心理困擾對復發與存活之影響

Abstract

頭頸癌為台灣最常見的十大癌症之一，而癌症病人在診斷時即造成生理與心理上極大的壓力與衝擊，頭頸癌病人在經歷積極癌症治療後，造成外觀、體力、進食等功能上的改變外，病人整體生活也帶來相當大的影響，其中心理困擾對於頭頸癌病人的影響更甚於多數其他癌症病人，由於大部分研究皆已證明生理因素，如：疾病診斷、期別、症狀等會影響疾病預後及存活，雖然部分研究指出心理因素也可能有所影響，但對於心理困擾是否影響疾病復發、甚至影響存活，相關研究相對有限，也缺乏長期追蹤及深入探討，因此，本研究目的為 (1) 探討頭頸癌病人其心理困擾、症狀嚴重度、疾病復發與存活之特質；(2) 探討頭頸癌病人人口學特性、疾病特性、症狀嚴重度、心理困擾各變項對疾病復發與存活之關係及差異；(3) 探討在控制疾病期別與症狀後，頭頸癌病人疾病復發與存活之預測因子為何；(4) 探討頭頸癌病人心理困擾之影響因子。本研究期間為2010年7月至2015年12月，採用前瞻性世代研究（prospective cohort study），於病人接受治療後六個月以結構式問卷，包含醫院焦慮憂鬱量表、症狀嚴重度量表、人口學基本資料等進行訪談，並以癌症登記資料追蹤其疾病復發與存活情形，並以邏輯式迴歸及存活分析了解其心理困擾及疾病預後；本研究結果發現，270位病人中有137位（50.7%）病人復發或因病程進展而死亡，76位（28.1%）病人死亡，在復發的顯著預測因子部分，包含淋巴分期為有淋巴侵犯者（HR=1.67, p=0.035）、症狀嚴重度較高者（HR=1.12, p=0.015）、診斷後有持續使用菸、酒、檳榔者（HR=1.84, p=0.043）、有憂鬱問題者（HR=2.82, p=0.031）之復發風險較高。存活顯著預測因子部分，包含淋巴分期為有淋巴侵犯者（HR=3.95, p=0.000），症狀嚴重度較高者（HR=1.06, p=0.011），婚姻狀態為單身者（HR=1.79, p=0.041），有復發情形者（HR=4.63, p=0.000），及有憂鬱問題者（HR=2.67, p=0.007）之死亡風險較高。心理困擾部分，本研究約有32%病人確定有焦慮或憂鬱問題，其顯著預測因子包含，持續使用菸、酒、檳榔者有較高的焦慮風險（OR=10.56, p=0.002）及憂鬱風險（OR=9.09, p=0.004），婚姻狀態為單身者亦有較高的焦慮風險（OR=2.53, p=0.023）及憂鬱風險（OR=2.48, p=0.023），腫瘤分期為早期者有較高的焦慮風險（OR=3.72, p=0.002），而腫瘤分期為晚期者有較高的憂鬱風險（OR=3.65, p=0.002），症狀嚴重度較高者也有較高的焦慮風險（OR=1.02, p=0.020），而男性則有較高的憂鬱風險（OR=5.04, p=0.040）。由本研究結果發現，在控制疾病期別與症狀後，頭頸癌存活者持續有相當程度的心理困擾，且顯著的影響病人的疾病預後與存活，因此頭頸癌病人之心理健康仍是值得重視之議題，建議臨床醫護人員應規律的評估病人心理狀態，適時提供心理輔導或轉介，以促進病人治療後的心理調適，並進而改善疾病復發與存活情形。

Head and neck cancer (HNC) is one of the top ten most common cancers in Taiwan. The diagnosis of cancer can generate great stress and impact on physical and psychological. Progressive cancer treatment induced functional impairment, including appearance, physical performance, and eating, leading to daily life dysfunction, especially psychological distress. HNC patients’ psychological distress was reported higher than other cancer patients. Evidence reported biological factors (diagnosis, cancer stage, and symptom) contributed to the patients’ likelihood of prognosis and survival. Although some studies have explored psychological distress, limited is known about psychological distress affects the recurrence and survival and longitudinal follow-up this issue. The purposes of the study were to explore: (1) the characteristics of psychological distress, symptom severity, recurrence and survival; (2) the univariate effect of demographic and disease characteristic, symptom severity, and psychological distress on recurrence and survival; (3) the predictors of recurrence and survival after controlling the cancer stage and symptom; and (4) the predictors of psychological distress. This prospective cohort study was conducted from July 2010 to December 2015. A set of questionnaires, including Hospital Anxiety and Depression Scale (HADS), Symptom Severity Scale (SSS), and background information were assessed at 6 months after completing treatment. Recurrence and survival were analyzed from the Cancer Registry Database a medical center in northern Taiwan. Logistic regression and survival analysis were used to reveal the factors related to psychological distress and recurrence. A total of 270 HNC patients were included in this study. The results found that (1) of these patients, 137 patients (50.7%) were identified recurrence or death, and 76 patients (28.1%) were death; (2) patients with lymph invasion (HR=1.67, p=0.035), higher symptom severity (HR=1.12, p=0.015), continued alcohol, tobacco, and betel nut used post-treatment (HR=1.84, p=0.043), and depression (HR=2.82, p=0.031) were more likely to recurrence; (3) patients with lymph invasion (HR=3.95, p=0.000), higher symptom severity (HR=1.06, p=0.011), unmarried (HR=1.79, p=0.041), recurrence (HR=4.63, p=0.000), and depression (HR=2.67, p=0.007) were more likely to poor survival; and (4) of these patients, 18.2% were identified as depression cases. (4) of these patients, 32% were identified as anxiety cases or depression cases, patients were single (OR=2.53, p=0.023, OR=2.48, p=0.023, respectively), continued alcohol, tobacco, and betel nut used (OR=10.56, p=0.002, OR=9.09, p=0.004, respectively) post-treatment had more risk of psychological distress (anxiety and depression); patients with early cancer stage (OR=3.72, p=0.002) and higher symptom severity (OR=1.02, p=0.020) had more risk of anxiety; Male patients (OR=5.04, p=0.040) and had advanced cancer stage (OR=3.65, p=0.002) were significantly more likely to develop depression. HNC survivors still suffered from psychological distress after treatment, after controlling cancer stage and symptom. This study suggested that health care provides should routinely assess psychological distress and provide mental support or referral service to improve prognosis and survival.