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据推算，补充和替代医疗在美国的产值达数十亿美元，其增长归功于可获得性和市场推广的增加以及患者对于健康的信念、价值观与人生哲学的一致性，尤其对直接自我治疗的渴望。补充医疗被用于辅助常规癌症治疗，并且可能被用于替代常规术后治疗。癌症患者使用广泛的补充医疗，包括草药和植物、维生素和矿物质、中药、顺势疗法和自然疗法以及专门饮食。癌症患者选择使用补充医疗改善生活质量，并且感到更有希望。既往研究表明，按摩、针刺、瑜伽、冥想等补充医疗可以改善生活质量。因此，据推算48%～88%的癌症患者报告使用补充和替代医疗作为其疗法之一。虽然补充和替代医疗被广泛使用，但是评估补充医疗与生存之间相关性的研究非常有限。既往研究表明替代医疗（替代常规癌症疗法）与死亡风险增加相关，但是补充医疗、坚持常规癌症治疗、癌症患者接受补充药物治疗相比未接受补充药物治疗的总生存之间相关性尚不明确。大约三分之二的癌症患者认为补充医疗可以延长生命，三分之一希望可以治愈疾病。虽然补充医疗可能通过帮助患者耐受常规治疗并且完成推荐治疗而改善结局，但是由于延迟接受证实有效的常规癌症治疗和拒绝其他被推荐的常规癌症治疗，补充医疗可能引起生存不佳。 2018年7月19日，《美国医学会杂志》肿瘤学分册在线发表耶鲁大学医学院的大数据研究报告，通过大型全国数据库，比较接受常规癌症治疗±癌症补充医疗的患者特征、治疗依从性、总生存，分析补充医疗选择相关因素、补充医疗与常规癌症治疗开始延迟或拒绝进一步常规癌症治疗之间的相关性，以及这些因素对患者生存结局的影响。 该大样本人群队列回顾观察研究根据美国癌症学会和美国外科医师学会癌症委员会的全国癌症数据库1500个认证中心2004年1月1日～2013年12月31日被诊断为非转移性乳腺癌、前列腺癌、肺癌或结直肠癌的190万1815例患者数据，对年龄、临床分组分期、查尔森德约合并症评分、医疗保险类型、种族、诊断年份、癌症类型进行匹配，于2017年11月8日～2018年4月9日进行统计分析。补充医疗被定义为除了常规癌症治疗方式（手术、放疗、化疗、激素治疗）之外“其他未经证实、由非医疗人员实施的癌症治疗”。主要结局衡量指标为总生存、治疗依从性、患者特征。 结果，补充医疗组、常规对照组患者分别为258例（其中乳腺癌186例）、190万1557例（其中乳腺癌73万2050例）。根据匹配后主要分析：
补充医疗组与常规对照组相比：
根据多因素模型分析，排除治疗延迟或拒绝因素后，补充医疗组与常规对照组相比：
补充医疗组与常规对照组相比，不同癌症类型的5年总生存率：
补充医疗组与常规对照组相比，不同癌症类型的5年死亡风险：
不过，考虑治疗延迟或拒绝因素后，补充医疗组与常规对照组相比，5年死亡风险相似（风险比：1.39，95%置信区间：0.83～2.33）。 因此，根据该研究结果，接受补充医疗的患者拒绝其他常规癌症治疗比例显著较高，并且死亡风险高两倍，尤其乳腺癌、结直肠癌。该研究结果表明，与补充医疗相关的死亡风险，由拒绝常规癌症治疗引起。 JAMA Oncol. 2018 Jul 19. [Epub ahead of print] Complementary Medicine, Refusal of Conventional Cancer Therapy, and Survival Among Patients With Curable Cancers. Johnson SB, Park HS, Gross CP, Yu JB. Yale School of Medicine, New Haven, Connecticut. This cohort study compares overall survival, treatment adherence, and patient characteristics among patients with cancer receiving conventional cancer treatment with vs without complementary medicine. QUESTION: What patient characteristics are associated with use of complementary medicine for cancer and what is the association of complementary medicine with treatment adherence and survival? FINDINGS: In this cohort study of 1901815 patients, use of complementary medicine varied by several factors and was associated with refusal of conventional cancer treatment, and with a 2-fold greater risk of death compared with patients who had no complementary medicine use. MEANING: Patients who received complementary medicine were more likely to refuse other conventional cancer treatment, and had a higher risk of death than no complementary medicine; however, this survival difference could be mediated by adherence to all recommended conventional cancer therapies. IMPORTANCE: There is limited information on the association among complementary medicine (CM), adherence to conventional cancer treatment (CCT), and overall survival of patients with cancer who receive CM compared with those who do not receive CM. OBJECTIVES: To compare overall survival between patients with cancer receiving CCT with or without CM and to compare adherence to treatment and characteristics of patients receiving CCT with or without CM. DESIGN, SETTING, AND PARTICIPANTS: This retrospective observational study used data from the National Cancer Database on 1901815 patients from 1500 Commission on Cancer-accredited centers across the United States who were diagnosed with nonmetastatic breast, prostate, lung, or colorectal cancer between January 1, 2004, and December 31, 2013. Patients were matched on age, clinical group stage, Charlson-Deyo comorbidity score, insurance type, race/ethnicity, year of diagnosis, and cancer type. Statistical analysis was conducted from November 8, 2017, to April 9, 2018. EXPOSURES: Use of CM was defined as "Other-Unproven: Cancer treatments administered by nonmedical personnel" in addition to at least 1 CCT modality, defined as surgery, radiotherapy, chemotherapy, and/or hormone therapy. MAIN OUTCOMES AND MEASURES: Overall survival, adherence to treatment, and patient characteristics. RESULTS: The entire cohort comprised 1901815 patients with cancer (258 patients in the CM group and 1901557 patients in the control group). In the main analyses following matching, 258 patients (199 women and 59 men; mean age, 56 years [interquartile range, 48-64 years]) were in the CM group, and 1032 patients (798 women and 234 men; mean age, 56 years [interquartile range, 48-64 years]) were in the control group. Patients who chose CM did not have a longer delay to initiation of CCT but had higher refusal rates of surgery (7.0% [18 of 258] vs 0.1% [1 of 1031]; P<.001), chemotherapy (34.1% [88 of 258] vs 3.2% [33 of 1032]; P<.001), radiotherapy (53.0% [106 of 200] vs 2.3% [16 of 711]; P<.001), and hormone therapy (33.7% [87 of 258] vs 2.8% [29 of 1032]; P<.001). Use of CM was associated with poorer 5-year overall survival compared with no CM (82.2% [95% CI, 76.0%-87.0%] vs 86.6% [95% CI, 84.0%-88.9%]; P=.001) and was independently associated with greater risk of death (hazard ratio, 2.08; 95% CI, 1.50-2.90) in a multivariate model that did not include treatment delay or refusal. However, there was no significant association between CM and survival once treatment delay or refusal was included in the model (hazard ratio, 1.39; 95% CI, 0.83-2.33). CONCLUSIONS AND RELEVANCE: In this study, patients who received CM were more likely to refuse additional CCT, and had a higher risk of death. The results suggest that mortality risk associated with CM was mediated by the refusal of CCT. PMID: 30027204 DOI: 10.1001/jamaoncol.2018.2487 |
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