臺灣博碩士論文加值系統

乳癌為台灣女性第二好發癌症，死亡率高居婦女十大死因第四位。在台灣，已經有許多研究對於乳癌的流行病學、病理學、診斷與治療作了相當完整而深入的探討，臨床的結果已經有了共識。然而病人在治療介入後，社會資源耗用和病人接受治療後的感受等結果評量，也變成值得關心的議題。
本研究目的在於瞭解影響早期乳癌病人接受不同術式之因素，並針對其接受乳房保留手術（Breast-conservation surgery, BCS）或改良型乳房切除術（Modified Radical Mastectomy, MRM）後，其健康相關生活品質與所需之醫療費用。以北部某醫學中心88年7月1日至91年12月31日期間，診斷為早期乳癌病人並BCS或MRM，共計160位病人為研究對象，以樣本醫院提供病人基本資料後，進行病人人口學資料、目前治療狀況、及醫療費用申報資料之蒐集；並由研究者以EORTC QLQ- C30及EORTC QLQ-BR23中文標準化問卷調查其健康相關生活品質。本研究重要結果如下：
一、160名受訪病人中，近兩成病人接受BCS，八成病人接受MRM；目前治療狀況僅門診追蹤或賀爾蒙治療各佔一半。
二、160名受訪病人在住院費用部分，平均費用41,549元；其中手術費所佔總費用比例最高，其次是麻醉費。而在乳癌後續門診費用平均值87,739；其中藥費佔五成以上，而診療費次之。
三、BCS與MRM受訪病人在EORTC QLQ-C30與EORTC QLQ-BR23評分結果皆以失眠、疲倦、手臂症狀及全身性治療為自訴最嚴重之問題。複迴歸分析結果：年齡會顯著影響「情緒功能」得分：在控制了其他變項後，年紀越大的病人，其「情緒功能」得分顯著較高。而接受MRM術式之早期乳癌病人，其「身體意向」得分顯著較低。羅吉斯複迴歸分析也顯示：接受MRM術式之早期乳癌病人，其「情緒功能」得分為高得分之機率，為接受BCS之早期乳癌病人之4.509倍。而在「身體意向」得分則以接受BCS術式之早期乳癌病人其得分為高得分之機率，為接受MRM之早期乳癌病人之3.268倍。
四、從複迴歸模式中可知，接受MRM術式之早期乳癌病人其住院總醫療費用比接受BCS術式之早期乳癌病人多2,785元；而門診總醫療費用則呈現年紀越大的病人，其後續的門診費用越低；接受MRM術式之早期乳癌病人，其乳癌治療相關門診醫療費用比接受BCS術式之早期乳癌病人少39,747元；臨床期別為第Ⅱ期的病人，在費用上也是顯著高於第Ⅰ期的病人。羅吉斯複迴歸分析也顯示：接受MRM術式之早期乳癌病人，其總住院醫療費用屬於高費用之機率為接受BCS之早期乳癌病人之2.415倍；接受BCS術式之早期乳癌病人乳癌治療相關門診醫療費用屬於高費用之機率為接受MRM之早期乳癌病人3.831倍；而年齡愈高，門診費用屬於高費用的機率越低(b=-0.0823)；臨床期別為第Ⅱ期之乳癌病人，其乳癌相關門診醫療費用屬於高費用之機率為第I期之乳癌病人之2.829倍。
本研究結果發現：BCS之總醫療費用較MRM高，但其健康相關生活品質大致上也較佳，顯示BCS適用於大多數早期乳癌病人。建議除了由乳房外科醫師、腫瘤放射線醫師、腫瘤內科醫師等共同討論與評估之外，病人也能參考本研究之結果，參與決定術式治療之選擇。

Breast cancer is the second most prevalent cancer of woman in Taiwan and its mortality rate ranks the fourth among the ten leading causes of death in Taiwan. There exist many studies focused on breast cancer epidemiology, pathology, diagnosis, and treatment in Taiwan. However, patients’ feelings, quality of life, and cost after intervention of treatments, are also meaningful subjects that deserve study.
The purposes of this study were to find out influence factors of patient underwent breast-conservation surgery (BCS) or modified radical mastectomy (MRM). Also to investigate the health-related quality of life (HRQoL) and cost of care for patients underwent BCS and MRM. . Study sample were 160 patients with early stages breast cancer undergoing treatment in one medical center in Taipei from July 1 1999 to December 31 2002. Data were collected by interviewing patients with telephone. The questionnaire used contains the Taiwan (Chinese) versions of EORTC QLQ-C30, EORTC QLQ-BR23 modules, basic demographic questions and out of pocket expenditures. Additional demographic data, the status of treatment, and insurance claim data of medical expenditures of these patients were provided by the study hospital.
The major results of this study are as follow:
1. Of the 160 patients interviewed, about 20% received BCS, and 80% received MRM. Almost half of the patients were undergoing Tamoxifen therapy.
2. The average medical expenditures in the period of hospitalization was NT$ 41,549, surgery cost ranks the highest, and anesthetic cost ranks the second. The average medical expenditures for follow-up visit was NT$ 87,739. Drug cost accounted for the highest proportions of outpatient care.
3. In terms of the score of EORTC QLQ-C30 and EORTC QLQ-BR23, “insomnia”, “fatigue”, “arm symptoms”, and “systemic therapy side effects” were the most serious problems. The result of multiple regression analysis showed that age positively affects the scores of “Emotional functional”. Patients who received MRM had “body image” scores significantly lower than patients who received BCS. According to the results of logistic regression analysis, patients who received MRM had higher chance of being classified at high “emotional functional” scores than BCS patients (OR=4.509). Patients Received BCS had higher chance of being classified at high’ “Body image” scores than MRM patients’ (OR=3.268).
4. In multiple regression analysis, we find that patients received MRM whose hospitalization medical expenditures were higher than BCS. In ambulatory medical expenditures, age and clinical stages were negatively correlated. From the results of the logistic regression analysis, we find that patients who received MRM had higher chance of being classified at high hospitalization medical expenditures than BCS patients (OR=2.415). Patients received BCS had higher chance of being classified at high ambulatory expenditures than MRM patients’ (OR=3.831). Patients who were at clinical stage Ⅱ had a higher chance of being classified at high ambulatory expenditures than that of the clinical stage Ⅰ (OR=2.829).
Based on the results of this study, we find that the total medical expenditures for BCS were higher than that of MRM. But the HRQoL for BCS patients was also better than that for MRM patients. These results suggest that Breast-conservation surgery can be recommended to most of the early-stages breast cancer patients. We suggest that patients be included in the decision process when counseling with a surgeon, an oncology radiologist, and an oncologist.

致謝 I
中文摘要 II
Abstract IV
第一章 緒論 1
第一節 研究背景 1
第二節 研究動機與目的 4
第二章 文獻探討 5
第一節 乳癌流行病學、治療方式與預後 5
第二節 疾病成本與健康相關生活品質之測量 15
第三節 乳癌治療實證研究及經濟評估 23
第四節 綜合討論 24
第三章 研究設計與方法 26
第一節 研究設計 26
第二節 研究假說 27
第二節 研究假說 28
第三節 研究工具與材料 29
第四節 資料處理與分析方法 36
第四章 研究結果 37
第一節 描述性統計分析結果 37
第二節 雙變項統計分析結果 47
第三節 多變項統計分析結果 65
第五章 討論 76
第一節 研究資料品質 76
第二節 重要結果討論 79
第三節 研究限制 82
第六章 結論與建議 83
第一節 結論 83
第二節 建議 86
參考文獻 87
附錄一 國際疾病分類代碼一覽表 94
附錄二 處置代碼 95
附錄三 EORTC QLQ-C30計分公式 96
附錄四 EORTC QLQ-BR23計分公式 97
附錄五 SEER Summary Staging Manual-2000: Breast 98
附錄六 EORTC 問卷使用同意書 102
附錄七 本研究結構式問卷 103
附錄八 乳癌手術之相關規定 108
表目錄
表1-1 台灣與美國在乳癌臨床分期比較 3
表2-1 乳癌分期之定義與其處置 12
表2-2 EORTC QLQ-C30問卷題目及本土測試信度 20
表2-3 EORTC QLQ-BR23問卷題目及本土測試信度 20
表3-1收案病人條件表 27
表3-2 研究變項-自變項 34
表3-3 研究變項-依變項 35
表4-1 問卷回收情形 37
表4-2 受訪病人特質 41
表4-3 受訪病人「健康相關生活品質問卷」評分結果：EORTC QLQ-C30問卷 42
表4-4 受訪病人「健康相關生活品質問卷」評分結果：EORTC QLQ-BR23問卷 43
表4-5 病人申報醫療費用描述性統計結果 44
表4-5 病人申報醫療費用描述性統計結果（續） 45
表4-6 病人自費部分描述性統計 46
表4-7 病人特質與不同術式之統計分析結果 50
表4-8 受訪病人「健康相關生活品質問卷」答案次數分配及百分比：EORTC QLQ-C30問卷 51
表4-8 受訪病人「健康相關生活品質問卷」答案次數分配及百分比：EORTC QLQ-C30問卷（續） 52
表4-8 受訪病人「健康相關生活品質問卷」答案次數分配及百分比：EORTC QLQ-C30問卷（續） 54
表4-9 受訪病人「健康相關生活品質問卷」答案次數分配及百分比：EORTC QLQ-BR23問卷 55
表4-9 受訪病人「健康相關生活品質問卷」答案次數分配及百分比：EORTC QLQ-BR23問卷（續） 56
表4-9 受訪病人「健康相關生活品質問卷」答案次數分配及百分比：EORTC QLQ-BR23問卷（續） 57
表4-10 受訪病人「健康相關生活品質問卷」評分結果：EORTC QLQ-C30問卷 58
表4-11 受訪病人「健康相關生活品質問卷」評分結果：EORTC QLQ-BR23問卷 59
表4-12 病人申報醫療費用統計分析結果－依術式分 60
表4-13 病人申報總醫療費用統計分析結果－依術式分 61
表4-14 病人出院後門診醫療費用統計分析結果－依術式分 62
表4-14 病人出院後門診醫療費用統計分析結果－依術式分（續） 63
表4-15 病人自費部分描述性統計－依術式分 64
表4-16 病人特性和住院總醫療費用之複迴歸分析 68
表4-17 病人特性和住院總醫療費用之羅吉斯迴歸分析（高費用=1，低費用=0） 69
表4-19病人特性和門診總醫療費用之羅吉斯迴歸分析（高費用=1，低費用=0） 71
表4-21 病人特性和健康相關生活品質（EORTC-C30）之羅吉斯迴歸分析：情緒功能得分（高得分=1，低得分=0） 73
表4-22 病人特性和健康相關生活品質（EORTC-BR23）之複迴歸分析：身體意向得分 74
表4-23 病人特性和健康相關生活品質（EORTC-BR23）之羅吉斯迴歸分析：身體意向得分（高得分=1，低得分=0） 75
表5-1 EORTC QLQ-C30及EORTC QLQ-BR23各題組評分結果內部一致性分析 78
圖目錄
圖1-1 台灣地區乳癌年齡標準化率之長期趨勢（民國80-89年） 3

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