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研究生:蔡淑美
研究生(外文):Shu Mei Tsai
論文名稱:穴位按壓對接受蕾莎瓦治療的肝癌病人癌因性疲憊、藥物不良反應和生活品質之成效
論文名稱(外文):The Effects of Acupressure on Cancer-Related Fatigue, Adverse Effects and Quality of Life for Hepatocellular Carcinoma Patients with Sorafenib
指導教授:蔡芸芳
指導教授(外文):Y. F. Tsai
學位類別:博士
校院名稱:長庚大學
系所名稱:臨床醫學研究所
學門:醫藥衛生學門
學類:醫學學類
論文種類:學術論文
論文出版年:2019
畢業學年度:107
語文別:中文
論文頁數:170
中文關鍵詞:肝癌蕾莎瓦癌因性疲憊穴位按壓藥物不良反應生活品質
外文關鍵詞:Hepatocellular carcinomaSorafenibacupressurecancer-related fatigueadverse effectsquality of life
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肝細胞癌是肝臟最常見的惡性腫瘤且為致死率極高的一種癌症。隨著醫療科學的發展,標靶治療儼然已經成為一種新的治療趨勢,而穴位按壓是一種安全、簡單易學、低成本且非侵入性的照護方式。本研究目的旨在探討穴位按壓對接受標靶治療的肝癌病人的癌因性疲憊、藥物不良反應和生活品質之成效。採重複測量、隨機對照試驗之研究設計,於中部一家醫學中心,將符合選樣條件的個案隨機分配至接受合谷穴、內關穴、足三里、三陰交和太衝穴位按壓的實驗組(n=38)以及接受常規護理的對照組(n=38)。研究成效指標以廣義估計方程式分析病人於介入前(T1)、介入一週後(T2)以及介入兩週後(T3)的三個時間點,其癌因性疲憊以及藥物不良反應的改善情形;並於介入前(T1)以及介入兩週後(T3)的兩個時間點,探討個案生活品質的改善情形。研究結果顯示,在介入一週後與介入兩週後,實驗組的疲憊降低成效優於對照組且達統計上顯著差異(Wald χ2 =62.61, p<.001;Wald χ2 =79.34, p<.001)。然而,介入兩週後,實驗組在手足皮膚反應之改善成效才顯著優於對照組(odds ratio=0.11, p<.01);實驗組的高血壓改善成效於介入一週後(odds ratio=0.26, p<.01)與介入兩週後(odds ratio=0.12, p<.001)明顯優於對照組;並且比較兩組在後測的血壓值,實驗組的血壓值均降低且達統計上顯著差異(Wald χ2 =5.67, p=.02;Wald χ2 =25.19, p<.001)。由於腹瀉方面,在介入兩週後,實驗組腹瀉程度較嚴重的人數已降至0人,因而無法計算估計參數,故本研究僅執行介入一週後的GEE估計模式分析,結果顯示實驗組的腹瀉獲得有效改善且達統計上顯著差異(odds ratio=0.04, p<.01)。生活品質部分,兩組在介入兩週後,癌症核心量表(QLQ C-30)的身體功能(Wald χ2 =26.15, p<.001)、角色功能(Wald χ2 =24.11, p<.001)、情緒功能(Wald χ2 =16.36, p<.001)、社會功能(Wald χ2 =12.10, p<.001)、認知功能(Wald χ2 =16.62, p<.001)和整體生活品質(Wald χ2 =45.15, p<.001);以及呼吸困難(Wald χ2 =10.95, p=.001)、失眠(Wald χ2 =14.86, p<.001)、食慾不振(Wald χ2 =18.57, p<.001)、噁心嘔吐(Wald χ2 =11.86, p=.001)、疲倦(Wald χ2 =28.99, p<.001)、疼痛(Wald χ2 =12.38, p<.001)、腹瀉(Wald χ2 =15.11, p<.001)等症狀以及財務困難(Wald χ2 =4.96, p=.03),實驗組改善幅度皆優於對照組並且達統計上顯著差異。另外,在肝癌病人特定生活品質(QLQ HCC-18)的營養(Wald χ2 =31.67, p<.001)、疲倦(Wald χ2 =15.22, p<.001)、疼痛(Wald χ2 =6.13, p=.01)、腹脹(Wald χ2 =10.11, p=.001)、黃疸(Wald χ2 =9.94, p<.01)、身體心像(Wald χ2 =17.01, p<.001)以及性生活(Wald χ2 =12.96, p<.001)等7個項目,實驗組改善幅度皆優於對照組且達統計上顯著差異。本研究結果證實穴位按壓在介入一週後,可以有效改善接受蕾莎瓦治療的肝癌病人之癌因性疲憊、藥物引起的手足皮膚反應、高血壓、腹瀉等症狀,並且在介入兩週後,能有效改善病人之癌因性疲憊、藥物不良反應以及生活品質。本研究結果可作為肝癌病人改善癌因性疲憊、藥物不良反應和生活品質居家自我照顧的實證依據。
Hepatocellular carcinoma (HCC) is one of the common liver malignancies but a lethal cancer. With the development of medical science, target therapy has become a new treatment trend. Acupressure is a safe, easy-to-learn, low-cost, and universal alternative therapy. The purpose of this study was to examine the effects of acupressure on cancer-related fatigue, adverse effects and quality of life (QoL) for HCC patients with Sorafenib. A repeated- measures and randomized controlled trial was designed. Patients met the inclusion criteria were randomly assigned to an experimental group (n = 38, received acupressure that contains five acupoints, including Hegu, Neiguan, Sanyinjiao, Zusanli, and Taichong) or a control group (n = 38, received routine care) at a medical center in central Taiwan. Generalized Estimating Equations (GEE) were used to examine the intervention effects in cancer-related fatigue and adverse effects at three different time points, as well as the intervention effects in QoL at two different time points. The experimental group had significantly less cancer-related fatigue than the control group at 1 week after the intervention (Wald χ2 =62.61, p<.001) and at 2 weeks after the intervention (Wald χ2 =79.34, p<.001). However, two weeks after the intervention, the experimental group exhibited significant improvement in hand-foot skin reaction versus the control group (odds ratio=0.11, p<.01). The experimental group had significantly better the improvement effect of hypertension than the control group at 1 week after the intervention (odds ratio=0.26, p<.01) and at 2 weeks after the intervention (odds ratio=0.12, p<.001). Moreover, compared the blood pressure level of the two groups at posttest, the experimental group also significantly reduced than the control group (Wald χ2 =5.67, p=.02;Wald χ2 =25.19, p<.001). The parameters could not be estimated because of the number of patients with severe diarrhea in the experimental group fell to zero at two weeks after the intervention, therefore the study only performed the analysis of the GEE at 1 week after the intervention. The GEE result indicated that diarrhea (odds ratio=0.04, p<.01) among patients in the acupressure group showed significantly greater improvement than patients in the control group at 1 week after the intervention. In QLQ C-30 scores, two weeks after the intervention, the experimental group revealed significant statistical improvement for the following functions and symptoms: physical (Wald χ2 =26.15, p<.001), role (Wald χ2 =24.11, p<.001), emotional (Wald χ2 =16.36, p<.001), social (Wald χ2 =12.10, p<.001), cognitive (Wald χ2 =16.62, p<.001), dyspnea (Wald χ2 =10.95, p=.001), insomnia (Wald χ2 =14.86, p<.001), appetite loss (Wald χ2 =18.57, p<.001), nausea/vomiting (Wald χ2 =11.86, p=.001), fatigue (Wald χ2 =28.99, p<.001), pain (Wald χ2 =12.38, p<.001), diarrhea (Wald χ2 =15.11, p<.001), financial impact (Wald χ2 =4.96, p=.03), and global QoL (Wald χ2 =45.15, p<.001). In addition, in QLQ HCC18 index-scores, two weeks after the intervention, the experimental group revealed significant statistical improvement for the following domains: nutrition (Wald χ2 =31.67, p<.001), fatigue (Wald χ2 =15.22, p<.001), pain (Wald χ2 =6.13, p=.01), abdominal swelling (Wald χ2 =10.11, p=.001), jaundice (Wald χ2 =9.94, p<.01), body image (Wald χ2 =17.01, p<.001), and sex life (Wald χ2 =12.96, p<.001). Our findings prove that acupressure improved cancer-related fatigue and adverse effects including hand-foot skin reaction, hypertension, and diarrhea after one-week intervention. Furthermore, after two-week intervention, acupressure revealed not only in improving cancer-related fatigue and adverse effects but also in QoL for HCC patients with Sorafenib. These results from our study provide an important evidence for HCC patients’ home-based self-care to improve their cancer-related fatigue, adverse effects, and QoL.
目 錄
指導教授推薦書……………………………………………………
口試委員會審定書…………………………………………………
誌謝 ……………………………………………………………… iii
中文摘要…………………………………………………………. iv
英文摘要…………………………………………………………. vi
目錄 ……………………………………………………………… ix
圖目錄………………………………………………………….… xii
表目錄 ……………………………………………………………. xiii
第一章 緒論
第一節 研究動機及重要性 ……………………………… 1
第二節 研究目的 ………………………………………… 5
第三節 研究問題 ………………………………………… 5
第四節 名詞界定 ………………………………………… 6
第二章 文獻查證
第一節 肝癌之概述 ……………………………………… 10
第二節 標靶治療對肝癌病人的影響 …………………… 16
第三節 癌因性疲憊 ……………………………………… 19
第四節 生活品質 ………………………………………… 22
第五節 穴位按壓 ………………………………………… 27
第六節 總結 …………………………………………… 37
第三章 研究方法
第一節 研究架構 ……………………………………… 40
第二節 研究設計 ……………………………………… 42
第三節 研究場所、對象及樣本數 …………………… 42
第四節 介入措施 ……………………………………… 44
第五節 研究工具與信、效度 …………………………… 46
第六節 研究步驟 ……………………………………… 51
第七節 資料分析方法 ………………………………… 52
第八節 研究倫理考量 ………………………………… 53
第四章 研究結果
第一節 收案過程 ……………………………………… 57
第二節 研究對象基本資料之描述 …………………… 59
第三節 研究對象的生化檢驗值、疲憊、藥物不良反應
、血壓和生活品質前測結果之描述 ………… 69
第四節 介入措施之成效 ……………………………… 79
第五章 討論
第一節 研究對象參與率 ……………………………… 106
第二節 研究對象基本資料之分析 …………………… 106
第三節 前測各變項之分析 …………………………… 109
第四節 介入措施之成效 ……………………………… 112
第六章 結論與建議
第一節 結論 ………………………………………… 117
第二節 護理應用 ……………………………………… 119
第三節 研究限制 ……………………………………… 120
第四節 未來研究方向之建議 ………………………… 121
參考文獻……………………………………………………… 122
附錄
附錄一 個案基本資料表………………………………… 149
附錄二 台灣版簡明疲憊量表…………………………… 151
附錄三 美國癌症研究院不良事件常用術語標準……… 152
附錄四 EORTC QLQ-C30 ……………………………… 153
附錄五 EORTC QLQ-HCC-18…………………………… 155
附錄六 穴位按壓日誌 …………………………………… 156
圖目錄
圖 2-1 巴塞隆納臨床肝癌分類準則……………………………… 14
圖 3-1 研究架構圖 ……………………………………………… 41
圖 3-2 按摩工具 ………………………………………………… 46
圖 3-3 接受標靶治療的肝癌病人穴位按壓之執行步驟 ……… 55
圖 4-1 收案流程圖 ………………………………………………… 58
圖 4-2 三個時間點兩組癌因性疲憊之變化趨勢 ………………… 81
圖 4-3 三個時間點兩組藥物不良反應-腹瀉之變化趨勢 ……… 83
圖 4-4 三個時間點兩組手足皮膚反應之變化趨勢 ……………… 85
圖 4-5 三個時間點兩組藥物不良反應-高血壓之變化趨勢 …… 87
圖 4-6 三個時間點兩組血壓之變化趨勢………………………… 89
圖 4-7 兩個時間點兩組EORTC-QLQ-C30整體生活品質之變化
趨勢 ……………………………………………………… 95
表目錄
表 2-1 Child-Pugh評分與分級 …………………………………… 15
表 2-2 國際疾病與健康相關問題之統計第十版—癌因性疲憊
的診斷要件 ……………………………………………… 20
表 2-3 各症狀常使用之配穴穴位名稱及位置 ………………… 33
表 2-4 肝癌病人因疾病或標靶治療引起的症狀比較表 ……… 38
表 3-1 穴位按壓介入措施之資料收集流程 …………………… 56
表 4-1 整體與不同組別研究對象之人口學特性 ……………… 63
表 4-2 整體與不同組別研究對象之疾病相關資料……………… 67
表 4-3 研究對象的生化檢驗值之分佈 ………………………… 71
表 4-4 研究對象的疲憊、血壓與藥物不良反應之分佈(前測) … 74
表 4-5 研究對象的生活品質之得分(前測) ……………………… 77
表 4-6 運用廣義估計方程式之參數估計表-癌因性疲憊總分 …… 81
表 4-7 運用廣義估計方程式之參數估計表-藥物不良反應-腹瀉… 83
表 4-8 運用廣義估計方程式之參數估計表-藥物不良反應-手足
皮膚反應…………………………………………………… 85
表 4-9 運用廣義估計方程式之參數估計表-藥物不良反應-高血壓 87
表 4-10運用廣義估計方程式之參數估計表-血壓 ………………… 89
表 4-11運用廣義估計方程式之參數估計表- EORTC-QLQ-C30
功能性層面總分…………………………………………… 92
表 4-12運用廣義估計方程式之參數估計表- EORTC-QLQ-C30
整體生活品質總分………………………………………… 95
表 4-13運用廣義估計方程式之參數估計表- EORTC-QLQ-C30
症狀層面總分 …………………………………………… 96
表 4-14運用廣義估計方程式之參數估計表-QLQ -HCC-18總分… 102
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