[[alternative]]Trajectories of physical, psychological distress and quality of life with Hepatocellular carcinoma

[[abstract]]前言肝細胞癌在疾病初期通常沒有症狀，當出現臨床症狀時通常已較晚期，病人須面對疾病在變化與治療的成效，加上肝細胞癌有著易復發的特性，病人不僅會有身體症狀之困擾，心理層面也會受到嚴重的衝擊，如此會干擾每日的生活功能，進而影響生活品質。但肝細胞癌相關研究著重在治療成效，病人在罹病歷程中之身心症狀反應之軌跡變化少被探討。目的本研究目的旨在探討肝細胞癌病人自診斷後，於接受治療過程中之身體症狀困擾程度、事件衝擊、憂鬱程度、害怕疾病進展和生活品質在六個月內之變化軌跡，並分析影響肝細胞癌病人的身體症狀、心理反應及生活品質的復原軌跡之預測因子。方法採前瞻性縱貫性研究設計(longitudinal design)，以台北市某醫學中心之胃腸內科、一般外科之病房與門診為收案場所。資料收集共計四次，分別在病人被確立診斷入院治療前、開始接受治療一個月後、治療後三個月及治療後六個月。以結構性問卷進行資料收集，研究工具包括人口學資料及疾病特徵、修正版身體症狀困擾查檢表、修訂版事件衝擊量表(IES-R)、醫院焦慮與憂鬱量表之憂鬱部分 (HADS-D)、簡版害怕疾病惡化量表 (FOP-Q-SF)及歐洲癌症研究與治療組織之一般性癌症病人生活品質量表 (EORTC QLQ-C30)。結果共收案123位出診斷病人，完成第二次收案的有99位病人，完成第三次問卷的有72位，追蹤至第四次共有58位病人。其中以男性居多 (69.1%)，平均年齡60.5歲 (SD = 12.3)，癌症期別以BCLC stage A的病人最多 (34.1%)，治療以接受手術切除最多 (26.0%)。身體困擾症狀在治療前、治療後一個月、三個月和六個月都是以疲倦、失眠、疼痛與腹脹居前四位，腹脹在治療後之改善較為顯著，疼痛亦見緩解，疲倦和失眠則先緩解後再增加，但均未達統計上之意義。在心理反應部分，事件衝擊感受會隨著時間緩解，到治療後三個月有顯著差異；憂鬱則是隨著時間增加而增加，在治療後一個月和六個月均有顯著差異；害怕疾病進展感受亦隨著時間而緩解，在治療後三個月有顯著改善。病人之身體功能、角色功能、認知功能及社會功能構面在治療後一個月、三個月及六個月皆較治療前時差，情緒功能及整體生活品質則顯示在治療後一個月、三個月及六個月均比治療前時佳。以類別成長模式 (Latent Growth Curve Model, LGCM) 探討肝細胞癌病人治療後各變項的軌跡變化，結果顯示身體症狀之疲倦、失眠、疼痛與腹脹之變化軌跡均為二組模式，影響其軌跡之相關因子均為癌症期別，而失眠軌跡則被AFP異常數值影響。事件衝擊亦為二組模式，影響因子則有疲倦、失眠、C肝病史、肝硬化病史及放射、標靶類等其他治療方式；憂鬱變化則為三組模式，單身、有工作、其他治療方式、疲倦、失眠、疼痛與腹脹均為其預測因子；害怕疾病惡化為二組模式，影響因子包括有工作及腹脹。在身體功能軌跡變化則是三組模式，影響因子為年齡、憂鬱和害怕疾病惡化；角色功能則為二組模式，癌症分期、疲倦和憂鬱為其影響因子；情緒功能亦為二組模式，影響因子包括疲倦和事件衝擊；認知功能之變化軌跡為二組模式，但無顯著之相關因子影響；社會功能為二組模式，受到疼痛及事件衝擊之影響；在整體生活品質之軌跡，亦為二組模式，年齡及疲倦為其相關預測因子。結論本研究結果提供臨床在照護病人過程要多關懷老年及有工作之肝細胞癌病人在疾病適應過程的變化，並提供需要的協助。而針對不同癌症分期、有B肝病史、肝硬化病史及使用標靶、放射等其他治療方式的病人，須謹慎地評估對病人的影響，以提供需要的醫療照護措施。另針對病人之疲倦、疼痛、失眠、腹脹、事件衝擊、憂鬱及害怕疾病進展等身心症狀，可視病人需要提供介入性措施，以幫助緩解困擾程度，增進活品質。[[abstract]]This longitudinal study explored the trajectories and precedent predictors for physical, psychological distress and the quality of life in hepatocellular carcinoma patients. The primary focus of this study was to characterize such trajectories of Taiwanese hepatocellular carcinoma survivors’ recovery during their treatment process. Based on the new Symptom Management Model, specific aims are to (a) describe changes of physical symptom distress, event impact, levels of depression, fear of disease progression and the quality of life (QOL) over time; and (b) identify determinants that affect recovery variables within 6 months following the diagnosis.A total of 123 liver cancer patients were recruited for this study. Data were collected at the baseline before treatment, 1-month, 3-month, and 6-month after treatment. The instrument includes the demographic and clinical characteristics, the modified Edmonton Symptom Assessment System, Impact of Event Scale- Revised (IES-R), Hospital Anxiety and Depression Scale –Depression (HADS-D), Fear of Progression Questionnaire-short form (FoP-Q-SF) and European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core-30 (EORTC QLQ-C30). SPSS 19.0 and SAS 9.2 were used to analyze data. Statistic methods included descriptive statistics, independent t-test, ANOVA, generalized estimating equations analysis (GEE), a latent class growth model (LGCM) and bivariate/ multivariate logistic regression.The result of this study revealed 2 groups trajectories for fatigue, insomnia, pain and abdominal distention, and BCLC staging was a significant related factor for them, whereas insomnia has shown to be affected by abnormal AFP. There were 3 groups trajectories for depression, single, treatment types, employment status, pain, and abdominal distension have respectively influenced the 3 groups of depression trajectories. For event impact, there were 2 groups trajectories, and fatigue, insomnia, C-hepatitis, liver cirrhosis history and treatment were significant determinants. Two groups trajectories for fear of cancer progression were identified, and employment status and abdominal distention were related predictors.Predictors for the three groups physical function trajectory were age, depression, and fear of cancer progression. The two-group trajectory of role and emotional functions were influenced by cancer staging, fatigue, depression, and event impact. The overall two-group QOL trajectory was predicted by age and fatigue.Findings from this study suggested various trajectories and significant determinants for physical, psychological distress and the Quality of Life over six months of treatment process. Insight information has been provided by this study for health care providers in caring patients with hepatocellular carcinoma. One important oncological care implication would be to develop intervention programs that tailored distinct groups who demonstrate severe symptoms, event impact, and fear of cancer progress with the goal to relieve their distress and facilitate QOL