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JAMA Oncology 2017年3月2日，《美国医学会杂志肿瘤学分册》在线发表罗彻斯特大学、美国癌症学会、西北大学、斯坦福大学、加利福尼亚圣迭戈国立大学、福克斯·蔡斯癌症中心、北卡罗来纳大学威明顿分校的荟萃分析报告，发现运动、心理干预是减少癌症相关疲劳的有效手段，在肿瘤治疗期间或治疗后同时使用这两种干预要显著优于现有药物治疗措施，但是与改善幅度无相关性。 癌症相关疲劳又称癌症疲劳综合征，是临床肿瘤常见的症状之一，与肿瘤及肿瘤治疗相关，是一种持续性、主观性疲倦劳累体验，长期存在并且干扰患者生活、导致病情加重、严重影响其生活质量，并很可能导致肿瘤治疗中断。因此认知并改善患者不同状态下的疲劳症状非常必要。在肿瘤患者治疗期间和治疗后，癌症相关疲劳仍是最普遍和最棘手的不良事件之一。有证据显示，运动与心理干预是癌症相关疲劳最好的治疗选择，这与通常的选择相反。通常的一线治疗选择为药物干预，但是数据显示，与目前研究涉及的药物干预相比，运动、心理干预的效果更好。 该研究对1999年1月1日～2016年5月31日PubMed、PsycINFO、CINAHL、EMBASE、Cochrane图书馆发表的文献进行检索，对检索到的研究数据进行荟萃分析，从而确定4种最常见的癌症相关疲劳推荐治疗方式（运动、心理治疗、运动＋心理治疗、药物治疗）哪种效果最好。主要结局衡量指标为癌症相关疲劳严重程度。 最后从17033篇参考文献选出113项随机临床研究的11525例参与者（女性占78%，平均年龄54岁，范围：35～72岁），近一半研究（53项，46.9%）开展于乳腺癌人群。其中，50项（44.2%）包括无转移性疾病患者、11项（9.7%）包括有转移性疾病患者、33项（29.2%）包括两种类型患者，其余研究未提供分期信息。 结果发现，运动、心理治疗、运动＋心理治疗、药物治疗对于改善治疗期间和治疗后癌症相关疲劳的加权效应平均值分别为：0.30、0.27、0.26、0.09（P值分别为：＜0.001、＜0.001、＜0.001、0.05）。 总体而言，与药物干预相比，使用运动、心理治疗、运动＋心理治疗进行癌症相关疲劳干预的总生存改善均较显著。 此外，癌症相关疲劳干预的疗效与肿瘤分期、初始治疗状态、干预治疗模式、干预治疗处理方式、心理状态、对照条件类型、意向治疗分析使用、疲乏程度有相关性。在所有报告癌症相关疲劳改善的患者和长期生存者中，早期病变和完成初始治疗的患者获益最大。 关于患者所选择的运动类型，有氧、无氧运动同样有效，散步、阻力训练、瑜伽等效果也都不错。 因此，肿瘤治疗期间和治疗后，运动与心理干预对于减少癌症相关疲劳有效，并且显著优于药物治疗。越来越多证据支持进行有规律体育活动，在对身体起到保护作用的同时，还可降低多种癌症风险。当癌症治疗结束时，运动也能缓解治疗的不良影响，并有助康复，而且部分数据显示对于正在积极治疗的乳腺癌和前列腺癌患者安全有效。其中2项研究还表明癌症长期生存者积极运动，不仅能减少化疗带来的不良影响，还能提高健康相关生活质量。临床医生应考虑将运动、心理干预作为癌症相关疲劳的一线治疗方式。 相关阅读 JAMA Oncol. 2017 Mar 2. [Epub ahead of print] Comparison of Pharmaceutical, Psychological, and Exercise Treatments for Cancer-Related Fatigue: A Meta-analysis. Mustian KM, Alfano CM, Heckler C, Kleckner AS, Kleckner IR, Leach CR, Mohr D, Palesh OG, Peppone LJ, Piper BF, Scarpato J, Smith T, Sprod LK, Miller SM. Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York; Behavioral Medicine Research Center, American Cancer Society, Washington, DC; Northwestern University, Rochester, New York; Stanford Cancer Institute, Stanford University, Stanford, California; School of Health and Human Services, National University, San Diego, California; Fox Chase Cancer Center, Philadelphia, Pennsylvania; School of Health and Applied Human Sciences, University of North Carolina Wilmington. IMPORTANCE: Cancer-related fatigue (CRF) remains one of the most prevalent and troublesome adverse events experienced by patients with cancer during and after therapy. OBJECTIVE: To perform a meta-analysis to establish and compare the mean weighted effect sizes (WESs) of the 4 most commonly recommended treatments for CRF-exercise, psychological, combined exercise and psychological, and pharmaceutical-and to identify independent variables associated with treatment effectiveness. DATA SOURCES: PubMed, PsycINFO, CINAHL, EMBASE, and the Cochrane Library were searched from the inception of each database to May 31, 2016. STUDY SELECTION: Randomized clinical trials in adults with cancer were selected. Inclusion criteria consisted of CRF severity as an outcome and testing of exercise, psychological, exercise plus psychological, or pharmaceutical interventions. DATA EXTRACTION AND SYNTHESIS: Studies were independently reviewed by 12 raters in 3 groups using a systematic and blinded process for reconciling disagreement. Effect sizes (Cohen d) were calculated and inversely weighted by SE. MAIN OUTCOMES AND MEASURES: Severity of CRF was the primary outcome. Study quality was assessed using a modified 12-item version of the Physiotherapy Evidence-Based Database scale (range, 0-12, with 12 indicating best quality). RESULTS: From 17033 references, 113 unique studies articles (11525 unique participants; 78% female; mean age, 54 [range, 35-72] years) published from January 1, 1999, through May 31, 2016, had sufficient data. Studies were of good quality (mean Physiotherapy Evidence-Based Database scale score, 8.2; range, 5-12) with no evidence of publication bias. Exercise (WES,0.30; 95% CI, 0.25-0.36; P<.001), psychological (WES,0.27; 95% CI, 0.21-0.33; P<.001), and exercise plus psychological interventions (WES,0.26; 95% CI, 0.13-0.38; P<.001) improved CRF during and after primary treatment, whereas pharmaceutical interventions did not (WES,0.09; 95% CI, 0.00-0.19; P=.05). Results also suggest that CRF treatment effectiveness was associated with cancer stage, baseline treatment status, experimental treatment format, experimental treatment delivery mode, psychological mode, type of control condition, use of intention-to-treat analysis, and fatigue measures (WES range, -0.91 to 0.99). Results suggest that the effectiveness of behavioral interventions, specifically exercise and psychological interventions, is not attributable to time, attention, and education, and specific intervention modes may be more effective for treating CRF at different points in the cancer treatment trajectory (WES range, 0.09-0.22). CONCLUSIONS AND RELEVANCE: Exercise and psychological interventions are effective for reducing CRF during and after cancer treatment, and they are significantly better than the available pharmaceutical options. Clinicians should prescribe exercise or psychological interventions as first-line treatments for CRF. PMID: 28253393 DOI: 10.1001/jamaoncol.2016.6914 |
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