臺灣博碩士論文加值系統

研究目的
本研究擬探討全國乳癌病人確診後焦慮症、憂鬱症及焦慮&憂鬱症的情形及其重要影響因子，以及其醫療資源利用情形、存活狀況等之間的差異，提出具體研究目的如下：
目的一、探討乳癌病人確診後罹患焦慮症、憂鬱症、焦慮&憂鬱症之重要影響因
子。
目的二、探討乳癌病人確診後有無焦慮症、憂鬱症、焦慮&憂鬱症醫療資源利用
的差異情形。
目的三、探討乳癌病人確診後有無焦慮症、憂鬱症、焦慮&憂鬱症存活狀況的差
異情形。

研究方法
本研究是採用全民健康保險研究資料庫進行一縱貫性研究，以回溯性方式進行分析。研究期間從自1996年至2010年，共計15年。研究對象是確診為乳癌病人(N=6,258)，探討其罹患焦慮症(n=2,154)、憂鬱症(n=19)、焦慮&憂鬱症(n=198)及無精神疾病(n=3,887)與醫療資源利用、存活的情形。本研究採用SPSS 19.0統計套裝軟體進行統計分析，包括卡方檢定、獨立樣本T檢定、對數迴歸分析、複迴歸分析及Cox迴歸分析進行資料推論性統計分析。

研究結果
年齡為影響焦慮症的顯著因子，手術方式為影響憂鬱症的顯著因子，乳癌病人施行MRM+TRAM手術者，相較於施行MRM者，其罹患憂鬱症的機率為10.18倍 (95% CI 2.88-36.04)，年齡和接受化學治療為影響焦慮&憂鬱症的顯著因子。
相較於無精神疾病組病人，在後續門診次數方面，焦慮症組病人一、三、五年內後續門診次數顯著多6.89次、21.72次、36.57次；憂鬱症組病人一、三、五內年後續門診次數顯著多16.67次、30.11次、25.61次；焦慮&憂鬱症組病人一、三、五年內後續門診次數顯著多18.35次、48.11次、65.63次。在後續門診醫療費用方面，焦慮症組病人三、五年內後續門診醫療費用顯著多28,735元、52,136元；焦慮&憂鬱症組病人三、五年內後續門診醫療費用比無精神疾病組病人顯著多52,068元、72,812元。在後續住院天數方面，焦慮&憂鬱症組病人五年內後續住院天數顯著多5.19天。在後續住院醫療費用方面，皆無達顯著差異。在後續總醫療費用方面，焦慮症組病人五年內後續總醫療費用顯著多39,712元；焦慮&憂鬱症組病人五年內後續總醫療費用顯著多83,629元。
在無病存活方面，相較於無精神疾病組病人，焦慮症組病人一年內無病存活的風險為0.66倍(95% CI 0.56-0.77)、三年內無病存活的風險為0.70倍(95% CI 0.64-0.77)、五年內無病存活的風險為0.73倍(95%CI 0.68-0.79)及焦慮&憂鬱症組病人一年內無病存活的風險為1.43倍(95%CI 1.04-1.95)。在整體存活方面，相較於無精神疾病組病人，焦慮症組病人一年內整體存活的風險為0.64倍(95%CI 0.55-0.7倍)、三年內整體存活的風險為0.69倍(95%CI 0.63-0.76)、五年內整體存活的風險為0.73倍(95%CI 0.67-0.79)及焦慮&憂鬱症組病人一年內整體存活的風險為1.41倍(95%CI 1.03-1.94)。

結論與建議
本研究發現年齡為乳癌病人罹患焦慮症的顯著影響因子；年齡和有接受化學治療為乳癌病人罹患焦慮&憂鬱症的顯著影響因子。在醫療資源利用方面，相較於無精神疾病乳癌病人，焦慮症組及焦慮&憂鬱症組於一年、三年和五年內後續門診次數、三年和五年內後續門診醫療費用及五年後續總醫療費用皆有顯著差異；憂鬱症組則於一年和三年內後續門診次數有顯著差異。在存活情形方面，相較於無精神疾病乳癌病人，焦慮症組有顯著較好的一、三、五年內的無病存活及整體存活狀況。
根據結果表示，近四成的乳癌病人有精神方面的疾病，故建議相關衛生機關除了加強乳癌篩檢以達早期診斷，早期治療外，更應該審慎注意與評估乳癌病人的情緒與精神狀況。此外，乳癌病患併發焦慮症者，雖然有顯著較好的存況狀況，但相對醫療資源利用情形有顯著成長，故應施以適當的介入措施，得以兼顧可讓病人獲得良好的預後，避免因病而貧，並且適當地控制醫療資源使用狀況，用有限的資源創造最大的效益，避免不必要的浪費，進而為病人與社會創造雙贏的局面。

Purpose
Breast cancer is the highest incidence in femal in Taiwan. This study aimed to explore the medical resource utilization and survival analysis among breast cancer patients initially diagnosed anxiety and depression disorders. The purposes of this study as follows:
I. To evaluate the associated factors of breast cancer patients initially diagnosed anxiety and depression disorders.
II. To evaluate the predictors of medical resource utilization of breast cancer patients initially diagnosed anxiety and depression disorders.
III. To evaluate the predictors of survival analysis of breast cancer patients initially diagnosed anxiety and depression disorders.
Methods
This study retrospectively use secondary database to analyze the associated factors and predictors of medical resource utilization and survival analysis among breast cancer patients (N=6,258) from January 1, 1996 to December 31, 2010. Multiple logistic regression, multiple liner regression and Cox proportional hazard model regression were employed in the study.
Results
The patient’s age predict the anxiety disorders and the patient’s age and chemotherapy predict the anxiety& depression disorders for breast cancer patients.
The part of Medical resource utilization, compared with non-disorder, the anxiety disorders’ patients respectively have significant more 6.89, 21.72, 36.57 outpatient visits in the initial first, third and fifth year.The depression disorders’ patients respectively have significant more 16.67, 30.11, 25.61 outpatient visits in the initial first, third and fifth year. The anxiety&depression disorders’ patients respectively have significant more 18.35, 48.11, 65.63 outpatient visits in the initial first, third and fifth year. The anxiety disorders’ patients respectively have significant more $28,735 and $52,136 outpatient medical expenses in the initial third and fifth year.The anxiety&depression disorders’ patients respectively have significant more $52,068 and $72,812outpatient medical expenses in the initial third and fifth year.
The anxiety&depression disorders’ patients have significant more 5.19 days of length of stay in the initial first year. The anxiety disorders’ patients have significant more $39,712 total medical expenses in the initial first year. The anxiety& depression disorders’ patients have significant more $83,629 total medical expenses in the initial first year.
The part of disease-free survival, compared with non-disorder, the anxiety disorders’ patients respectively have significant 0.66, 0.70, and 0.73 times of the risk in the initial first, third and fifth year. The anxiety & depression disorders’ patients have significant 1.43 times of the risk in the initial first year.
The part of overall survival, compared with non-disorder, the anxiety disorders’ patients respectively have significant 0.64, 0.69, and 0.73 times of the risk in the initial first, third and fifth year. The anxiety&depression disorders’ patients have significant 1.41 times of the risk in the initial first year.
Conclusion and recommendations
This study results indicated that nearly forty percent of breast cancer patients with mental illness. It is suggested that not only to strengthening the relevant health authorities to achieve early diagnosis of breast cancer screening and early treatment, but also careful attention should assess breast cancer patients with emotional and mental condition.

目錄
第一章 緒論 10
第一節 研究背景和動機 10
第二節 研究目的 14
第三節 預期貢獻 15
第四節 名詞解釋 16
第二章 文獻探討 19
第一節 乳癌簡介 19
第二節 焦慮症及憂鬱症簡介 25
第三節 確診後焦慮症、憂鬱症之情形及重要影響因子之實證研究 29
第四節 醫療資源利用之實證研究 40
第五節 存活情形之實證研究 52
第三章 研究方法 60
第一節 研究設計與架構 60
第二節 研究假說 63
第三節 研究資料與研究樣本 64
第四節 研究變項操作型定義 68
第五節 統計分析 78
第四章 研究結果 80
第一節 乳癌病人確診後有無精神疾病的在各變項間之差異情形 80
第二節 乳癌病人罹患精神疾病之重要影響因子 103
第三節 有無精神疾病的乳癌病人在醫療資源利用之差異情形 107
第四節 有無精神疾病的乳癌病人在存活狀況之差異情形 113
第五節 結論與建議 120
第一節 研究討論 120
第二節 研究貢獻、限制與未來方向 127
第三節 結論與建議 131
參考文獻 133

表目錄
表2- 1 乳癌分期 23
表2- 2 確診後焦慮症、憂鬱症之情形及重要影響因子之實證研究 35
表2- 3 醫療資源利用之實證研究 46
表2- 4 存活狀況之實證研究 56
表3- 1 資料庫操作型變項一欄表 75
表4- 1 無精神疾病組與焦慮症組在各自變項之差異分析 82
表4- 2 無精神疾病組與憂鬱症組在各自變項之差異分析 85
表4- 3 無精神疾病組與焦慮&憂鬱症組在各自變項之差異分析 88
表4- 4 無精神疾病組與焦慮症組在醫療資源利用之差異分析 92
表4- 5 無精神疾病組與憂鬱症組在醫療資源利用之差異分析 95
表4- 6 無精神疾病組與焦慮&憂鬱症組在醫療資源利用之差異分析 98
表4- 7 無精神疾病組、焦慮組、憂鬱組及焦慮&憂鬱組在一年無病存活率之差異分析 100
表4- 8 無精神疾病組、焦慮組、憂鬱組及焦慮&憂鬱組在三年無病存活率之差異分析 100
表4- 9 無精神疾病組、焦慮組、憂鬱組及焦慮&憂鬱組在五年無病存活率之差異分析 100
表4- 10 無精神疾病組、焦慮組、憂鬱組及焦慮&憂鬱組在一年整體存活率之差異分析 102
表4- 11 無精神疾病組、焦慮組、憂鬱組及焦慮&憂鬱組在三年整體存活率之差異分析 102
表4- 12 無精神疾病組、焦慮組、憂鬱組及焦慮&憂鬱組在五年整體存活率之差異分析 102
表4- 13 影響焦慮症之對數迴歸分析 104
表4- 14 影響憂鬱症之對數迴歸分析 105
表4- 15 影響焦慮&憂鬱症之對數迴歸分析 106
表4- 16 有無精神疾病之醫療資源利用情形複迴歸分析 111
表4- 17 有無精神疾病之無病存活Cox迴歸分析 115
表4- 18 有無精神疾病之整體存活Cox迴歸分析 118

圖目錄
圖1- 1台灣地區全癌症標準化發生率與死亡率長期趨勢 13
圖1- 2近十年來台灣地區女性乳癌死亡與發生人數趨勢分析 13
圖3- 1資料庫研究架構 62
圖3- 2 研究樣本篩選流程 67
圖4- 1 一年內無病存活之Cox迴歸分析圖 115
圖4- 2 三年內無病存活之Cox迴歸分析圖 116
圖4- 3 五年內無病存活之Cox迴歸分析圖 116
圖4- 4 一年內整體存活之Cox迴歸分析圖 118
圖4- 5 三年內整體存活之Cox迴歸分析圖 119
圖4- 6 五年內整體存活之Cox迴歸分析圖 119

附錄
附錄 1 Charlson 之ICD-9-CM 診斷碼編碼定義 140
附錄 2 疾病系統ICD9分類標準 141
附錄 3 荷爾蒙藥品 142

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中華民國生活調適愛心會，19期會訊，李俊德醫師
http://www.ilife.org.tw/Page_Show.asp?Page_ID=740
互動百科
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趙莉芬. (2011). 接受乳房重建手術乳癌婦女生活品質長期變化之前瞻縱貫性探討.
乳癌防治基金會,2013
台灣癌症防治網,2013
行政院衛生署國民健康局, 2012
台灣癌症臨床研究發展基金,2012
台安醫院乳癌中心,2013
http://www.tahsda.org.tw/breastcenter/main.php?mode=category&categoryID=3&subcategoryID=16
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