症状による進行がんの予後予測

症状による進行がんの生存予後予測の系統的レビュー論文を紹介します。

Marija Trajkovic-Vidakovic, et al: Symptoms tell it all: A systematic review of the value of symptom assessment to predict survival in advanced cancer patients. Critical Reviews in Oncology/Hematology Available online 30 March 2012, http://dx.doi.org/10.1016/j.critrevonc.2012.02.011

下記HPで全文見れるかもしれません。
http://www.sciencedirect.com/science/article/pii/S1040842812000509

まず緩和医療の時期をdisease palliation, symptom palliation, terminal palliationの3つに分類しています。各時期の定義は以下の通りです。このような分類の仕方は理解できますが、私は初めて聞きました。

In the first stage palliation is disease-directed with the aim of prolonging life and improving or maintaining the quality of life by means of treating the underlying malignancy.

The second stage (symptom-oriented palliation) starts when anti-tumor treatment is discontinued because of lack of effect and/or severe side-effects. The focus in this stage is quality of life and stabilization and prevention of symptoms.

The terminal stage refers to the point at which it becomes clear that the patient is in a progressive state of decline and that death is imminent. In this stage the emphasis is set on improving the quality of dying by constraining symptoms to minimize suffering with acceptance of a potential loss of cognitive, emotional and social functioning.

結果ですが、disease palliationの時期は、食欲不振、悪液質、体重減少、嚥下障害、疼痛が独立した生存予測因子でした。symptom palliationの時期は、錯乱、疲労、悪液質、呼吸困難、嚥下障害、吐気が独立した生存予測因子でした。

なお、terminal palliationの論文は3つしかありませんでした。その中には、疲労、悪液質、体重減少、認知障害が独立した生存予測因子という報告があります。

disease palliationは悪液質のない時期～前悪液質～悪液質、symptom palliationは悪液質～不応性悪液質、terminal palliationは不応性悪液質の時期と言える気がします。

特に悪液質、体重減少、嚥下障害は複数の時期で独立した生存予測因子となっています。嚥下も含めた栄養評価で、進行がん患者の予後予測が多少は可能かもしれません。願わくは嚥下も含めたリハ栄養介入で、嚥下・栄養改善、QOL改善、生存期間改善を目指したいですね。
Abstract
Purpose To determine the prognostic meaning of symptoms in patients with advanced cancer.

Design Medline, Embase, Cochrane and Cinahl databases were systematically explored. The predicting symptoms were also evaluated in the three stages of palliative care: disease-directed palliation, symptom-oriented palliation and palliation in the terminal stage.

Results Out of 3167 papers, forty-four papers satisfied all criteria. Confusion, anorexia, fatigue, cachexia, weight loss, cognitive impairment, drowsiness, dyspnea, dysphagia, dry mouth and depressed mood were associated with survival in ≥50% of the studies evaluating these symptoms. Multivariate analysis showed confusion, anorexia, fatigue, cachexia, weight loss, dyspnea and dysphagia as independent prognostic factors in 30–56% of the studies. In the stage of disease-directed palliation anorexia, cachexia, weight loss, dysphagia and pain and in the stage of symptom-oriented palliation confusion, fatigue, cachexia, weight loss, dyspnea, dysphagia and nausea were shown to be independent predictors of survival in >30% of the studies.

Conclusion Symptoms with independent predictive value are confusion, anorexia, fatigue, cachexia, weight loss, dyspnea and dysphagia. New insights are added by the variance between the three palliative stages.