本文選題：頭頸部腫瘤　切入點(diǎn)：放射治療　出處：《華中科技大學(xué)》2014年博士論文　論文類型：學(xué)位論文

【摘要】：目的 放射治療是頭頸部腫瘤最主要的治療方法之一。然而,盡管放療技術(shù)不斷在進(jìn)步,口腔黏膜炎(Oral Mucositis, OM)仍是頭頸部腫瘤放療過(guò)程中最常見(jiàn)的毒副反應(yīng)之一。OM常引起不同程度的口腔及咽部疼痛,嚴(yán)重者需要阿片類藥物鎮(zhèn)痛,同時(shí)常影響患者進(jìn)食,引起營(yíng)養(yǎng)攝入障礙,嚴(yán)重影響患者生活質(zhì)量,甚至影響治療計(jì)劃順利進(jìn)行,并增加住院日及治療花費(fèi)。盡管OM對(duì)患者生活質(zhì)量及治療均造成了極大影響,其在臨床工作中卻很少得到足夠且正確的預(yù)防及治療。本研究旨在：1)調(diào)查OM在頭頸部腫瘤放療患者中的發(fā)病率、影響因素及導(dǎo)致的結(jié)果；2)研究放療相關(guān)OM的臨床診療現(xiàn)狀；3)調(diào)查腫瘤內(nèi)科醫(yī)師對(duì)OM診療知識(shí)的知曉及態(tài)度。 方法 1.以2013年11月至2014年1月同濟(jì)醫(yī)院腫瘤放療中心頭頸部放療患者為研究對(duì)象,收集患者一般信息(性別、年齡、身高、體重、診斷、誘導(dǎo)化療情況等),以美國(guó)國(guó)家癌癥研究所(National Cancer Institute, NCI)常見(jiàn)不良反應(yīng)分級(jí)標(biāo)準(zhǔn)(Common Terminology Criteria for Adverse Events, CTCAE)每周對(duì)患者OM情況、白細(xì)胞計(jì)數(shù)、中性粒細(xì)胞計(jì)數(shù)等進(jìn)行評(píng)估,直至治療結(jié)束,并記錄患者同步化療情況及治療結(jié)束后體重變化。 2.調(diào)查以上患者口腔黏膜炎診斷情況,并以2013年癌癥支持治療多國(guó)協(xié)會(huì)／國(guó)際口腔腫瘤協(xié)會(huì)(MASCC/ISOO)抗腫瘤治療相關(guān)OM臨床實(shí)踐指南為基礎(chǔ),對(duì)患者接受的OM相關(guān)治療進(jìn)行調(diào)查,了解其診療現(xiàn)狀。 3.設(shè)計(jì)調(diào)查問(wèn)卷,調(diào)查腫瘤內(nèi)科醫(yī)師對(duì)放療相關(guān)OM流行病學(xué)、診斷分級(jí)標(biāo)準(zhǔn)、診療方法及診療指南的知曉情況,分析臨床醫(yī)師對(duì)放療相關(guān)OM的認(rèn)識(shí)及態(tài)度。 結(jié)果 1.流行病學(xué)調(diào)查結(jié)果： (1)共納入頭頸部腫瘤患者101名,93.1%的患者出現(xiàn)OM,嚴(yán)重OM(3級(jí)及以上)為66.3%。嚴(yán)重OM的危險(xiǎn)因素包括,患者相關(guān)因素：原發(fā)腫瘤位于鼻咽部(OR=3.7,95%CI1.6～8.9)及放療過(guò)程中出現(xiàn)白細(xì)胞減少(OR=5.3,95%CI2.1-13.3)；治療相關(guān)因素：接受了誘導(dǎo)化療(OR=5.7,95%CI1.6～20.1)、同步化療(OR=5.4,95%CI2.2～13.3)及放療累積劑量超過(guò)70Gy(OR=18.4,95%CI2.4～143.2)。 (2)OM持續(xù)時(shí)間平均為(5.0±1.4)w。嚴(yán)重OM平均持續(xù)(3.3+0.8)w。原發(fā)腫瘤位于鼻咽部(5.4±1.8w vs.4.5±1.9w, P=0.002)及接受了同步化療(5.3+0.8wvs.4.4±2.0w,P=0.001)的患者OM持續(xù)時(shí)間較長(zhǎng)。 (3)放療后患者體重下降平均為(4.0±2.7)kg,50.5%患者接受了腸外營(yíng)養(yǎng)支持,33.7%的患者需要住院治療,平均住院時(shí)間為(10.2.±6.9)天。嚴(yán)重OM患者體重下降更多(5.0±2.5kg vs.1.7±1.7kg,P=0.000),且腸內(nèi)營(yíng)養(yǎng)應(yīng)用(OR=7.4,95%CI2.8～19.5)、阿片類藥物使用(OR=7.3,95%CI1.6～33.4)及住院風(fēng)險(xiǎn)(OR=14.6,95%CI3.2～66.0)更高。 2.頭頸部放療相關(guān)OM的診療現(xiàn)狀： (1)43.6%的患者病歷中有OM相關(guān)的診斷或記錄。進(jìn)行了明確診斷的患者僅占11.7%,僅3名(3.2%)患者OM診斷中包含了分級(jí)。 (2)用于預(yù)防/治療OM的措施繁多,其中僅7.7%患者接受了預(yù)防OM的措施,全部為基礎(chǔ)口腔護(hù)理。使用率最高的5項(xiàng)措施包括：靜脈注射抗細(xì)菌藥物(73.3%)、基礎(chǔ)口腔護(hù)理(52.5%)、靜脈注射地塞米松(46.5%)、霧化吸入(46.5%)及利多卡因漱口(35.6%)。 (3)嚴(yán)重OM患者使用抗細(xì)菌藥物(OR=14.5,95%CI4.9～42.8)的風(fēng)險(xiǎn)更高。 3.臨床醫(yī)師對(duì)頭頸部放療相關(guān)OM的認(rèn)識(shí)及態(tài)度： (1)50%醫(yī)師認(rèn)同頭頸部放療相關(guān)OM發(fā)病率超過(guò)80%,近一半(48.3%)醫(yī)師認(rèn)為其對(duì)患者產(chǎn)生了較大影響。但僅58.6%的醫(yī)師認(rèn)為自己對(duì)OM的診治足夠重視。 (2)僅20.7%的醫(yī)師會(huì)定期對(duì)患者進(jìn)行口腔檢查(至少1次／周)。參與調(diào)查醫(yī)師最常用的OM分級(jí)標(biāo)準(zhǔn)為WHO標(biāo)準(zhǔn)(50.0%)。十分了解或完全了解OM診斷分級(jí)標(biāo)準(zhǔn)的醫(yī)師僅占14.3%。 (3)常規(guī)對(duì)頭頸部放療患者進(jìn)行OM預(yù)防的醫(yī)師占31.0%。醫(yī)師認(rèn)為有效的預(yù)防／治療措施前5位包括：基礎(chǔ)口腔護(hù)理(94.7%)、局部麻醉藥物(利多卡因等)(78.9%)、地塞米松(78.9%)、營(yíng)養(yǎng)支持(78.9%)、粒(巨噬細(xì)胞)-集落刺激因子(G(M)-CSF)(68.4%)。無(wú)效措施前5位包括：蜂蜜(36.8%)、洗必泰漱口水(21.1%)、芐達(dá)明漱口水(21.1%)、硫糖鋁漱口水(15.8%)、低劑量激光療法(15.8%)。 (4)對(duì)于MASCC/ISOO癌癥相關(guān)OM指南,41.4%的醫(yī)師不了解。大部分(62.1%)的醫(yī)師認(rèn)為在管理頭頸部放療相關(guān)OM方面接受的培訓(xùn)不足。 結(jié)論 1.頭頸部放療相關(guān)OM發(fā)病率高,幾乎不可避免。原發(fā)腫瘤位于鼻咽部、接受了誘導(dǎo)化療、同步化療、放療累積劑量超過(guò)70Gy及放療過(guò)程中出現(xiàn)白細(xì)胞減少與OM的嚴(yán)重程度相關(guān)。OM與患者體重下降、腸內(nèi)營(yíng)養(yǎng)應(yīng)用、阿片類藥物使用及住院率增加相關(guān)。 2.目前臨床實(shí)踐中對(duì)于頭頸部放療相關(guān)OM的診療尚不規(guī)范,漏診率高。治療OM的藥物種類繁多,但多為經(jīng)驗(yàn)性用藥,對(duì)現(xiàn)有循證醫(yī)學(xué)證據(jù)的實(shí)施度不足。 3.問(wèn)卷調(diào)查顯示醫(yī)師對(duì)OM缺乏重視。對(duì)相關(guān)理論知識(shí),包括診療指南的知曉度低,造成醫(yī)師對(duì)OM預(yù)防及治療的認(rèn)識(shí)存在很大誤區(qū)。突出了對(duì)腫瘤科醫(yī)師進(jìn)行OM相關(guān)診療知識(shí)培訓(xùn)的必要性。
[Abstract]:objective
Radiotherapy is one of the main methods of treatment of head and neck cancer. However, despite advances in radiotherapy of oral mucositis (Oral, Mucositis, OM) is still the most common adverse reaction of radiotherapy for head and neck cancer in the process of.OM is often caused by oral and pharyngeal pain in different degree, serious need for opioid analgesia at the same time, often affect patients caused by eating, nutrition disorder, seriously affect the life quality of patients, and even affect the treatment plan, and increased hospitalization and treatment costs. Although OM on quality of life of patients and treatment were made into a great influence in the clinical work has rarely been enough and correct prevention and treatment. The purpose of this study is to investigate: 1) the incidence of OM in patients with head and neck cancer radiotherapy rate, influencing factors and results; 2) clinical research status of radiotherapy of OM; 3) the investigation of tumor The knowledge and attitude of the physician on the knowledge of OM diagnosis and treatment.
Method
From November 2013 to January 2014 1. to Tongji Hospital cancer radiotherapy center head and neck radiotherapy patients as the research object, collecting general information (gender, age, height, weight, diagnosis, chemotherapy, etc.) to the National Cancer Institute (National Cancer, Institute, NCI) common adverse reactions (Common Terminology Criteria for standard Adverse Events CTCAE), weekly for patients with OM, white blood cell count, neutrophil count evaluation, until the end of treatment, and record the weight change of patients with synchronous chemotherapy and after treatment.
2., we investigated the diagnosis of oral mucositis in the above patients. Based on the OM clinical practice guideline of cancer support therapy of the Multinational Association / International Association of oral cancer (MASCC/ISOO) in 2013, we investigated the OM related treatment of patients and found its diagnosis and treatment.
3., design a questionnaire to investigate the awareness of radiotherapy related OM epidemiology, diagnostic grading criteria, diagnosis and treatment guidelines, and analyze the clinicians' perceptions and attitudes towards radiotherapy related OM.
Result
1. the results of epidemiological survey:
(1) a total of 101 patients with head and neck cancer, 93.1% patients with OM and severe OM (grade 3 and above) for severe OM 66.3%. including risk factors, related factors of patients with primary tumor in the nasopharynx (OR=3.7,95%CI1.6 ~ 8.9) and radiotherapy leukopenia (OR=5.3,95%CI2.1-13.3) treatment; factors: received induction chemotherapy (OR=5.7,95%CI1.6 ~ 20.1), chemotherapy (OR=5.4,95%CI2.2 ~ 13.3) and cumulative doses of radiotherapy more than 70Gy (OR=18.4,95%CI2.4 ~ 143.2).
(2) the average duration of OM was (5 + 1.4) W., and severe OM lasted for an average of (3.3+0.8) w.. The primary tumor located in the nasopharynx (5.4 + 1.8W vs.4.5 + 1.9W, P=0.002) and the patients who received concurrent chemotherapy (5.3+0.8wvs.4.4 + 2.0W, P=0.002) lasted longer.
(3) after radiotherapy for patients with weight loss on average (4 + 2.7) kg, 50.5% patients received parenteral nutrition, 33.7% patients required hospitalization, the average hospitalization time (10.2. + 6.9) days. Body weight decreased more in patients with severe OM (5 + 2.5kg vs.1.7 + 1.7kg, P=0.000), and intestinal application of nutrition (OR=7.4,95%CI2.8 ~ 19.5), the use of opioids (OR=7.3,95%CI1.6 ~ 33.4) and the risk of hospitalization (OR=14.6,95%CI3.2 ~ 66) higher.
2. the status of diagnosis and treatment of OM related to radiotherapy in the head and neck:
(1) 43.6% of the patients had a OM related diagnosis or record. Only 11.7% of the patients were diagnosed, and only 3 (3.2%) had a classification in the OM diagnosis.
(2) for the prevention / treatment of OM range, which only 7.7% of the patients received OM prevention measures, all based on oral care. Including the use of the highest rate of 5 measures: intravenous injection of anti bacteria drugs (73.3%), (52.5%), oral care based intravenous injection of dexamethasone (46.5%), atomization inhalation of lidocaine gargle (46.5%) and (35.6%).
(3) the risk of using anti bacterial drugs (OR=14.5,95%CI4.9 ~ 42.8) in severe OM patients is higher.
3. cognition and attitude of clinicians to head and neck radiotherapy related OM:
(1) 50% physicians agree that the incidence of OM related to head and neck radiotherapy is more than 80%, nearly half (48.3%) of doctors believe that it has a great impact on patients. However, only 58.6% of doctors think they pay enough attention to the diagnosis and treatment of OM.
(2) only 20.7% of the physicians regularly perform oral examination on their patients (at least 1 times / week). The most commonly used OM grading standard is WHO standard (50%). Physicians who know or understand OM diagnostic grading standards only account for 14.3%..
(3) conventional radiotherapy in patients with head and neck OM prevention physicians accounted for 31.0%. physicians believe that prevention / treatment is effective measures before the 5 include: basic oral care (94.7%), local anesthetic (lidocaine and dexamethasone) (78.9%), (78.9%), nutritional support (78.9%), grain (macrophage colony -) stimulating factor (G (M) -CSF) (68.4%). 5 effective measures include: (36.8%) honey, chlorhexidine mouthwash slobber (21.1%), (21.1%) benzydamine mouthwash slobber, sucralfate mouthwash slobber (15.8%), low dose laser therapy (15.8%).
(4) 41.4% of physicians do not know about OM guidelines for cancer related MASCC/ISOO. Most (62.1%) of doctors believe that there is insufficient training in management of head and neck radiotherapy related OM.
conclusion
1. head and neck radiotherapy related to the incidence of OM is high, almost inevitable. The primary tumor in the nasopharynx, received induction chemotherapy, chemotherapy, radiotherapy and cumulative dose more than 70Gy in the process of radiotherapy leukopenia weight related to severity of.OM and patients with OM decreased, the application of enteral nutrition, opioid use and the hospitalization rate increased.
2., in the current clinical practice, the diagnosis and treatment of head and neck radiotherapy related OM is still not standardized, and the rate of missed diagnosis is high. There are many kinds of drugs for OM treatment, but most of them are empirical medication, and the implementation of evidence-based medicine is insufficient.
3., a questionnaire survey showed that doctors did not pay much attention to OM. There was a lot of misunderstanding about the theoretical knowledge, including the awareness of diagnosis and treatment guidelines, which led to the misunderstanding of OM prevention and treatment. It highlighted the necessity of training OM oncology related knowledge for oncologists.

【學(xué)位授予單位】：華中科技大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2014
【分類號(hào)】：R739.91

【共引文獻(xiàn)】

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