众所周知，晚期癌症患者的照料者负担很重，生活质量也有所下降。然而，旨在减轻上述影响的干预措施却很少。2014美国临床肿瘤学会（ASCO）年会所发布的ENABLE III研究中，来自美国阿拉巴马大学伯明翰分校综合癌症中心等机构的研究者探讨了晚期癌症姑息治疗启动时间对照料者的影响。结果显示，姑息治疗启动越早，照料者的精神健康状况更好，心理舒适度更高。以下为研究细节。
研究方法：
该随机对照研究于2010年10月11日至2013年9月5日之间进行，共纳入了207名患者及122名非专业照料人员。即刻干预组在随机化分组后立刻启动ENABLE（生命终结前的教育、滋养、建议），这是一项基于电话的肿瘤姑息治疗干预项目；而延迟组在随机化分组12周后启动ENABLE。研究者分别使用癌症患者照顾者生活质量量表、流调中心用抑郁量表及Montgomery Borgatta照料者负担量表测定了照料者的生活质量（QOL）、抑郁及负担状况，其中后者又分为主观负担（SB）、客观负担（OB）及要求负担（DB），测定时间为第0、6、12、18、24周；24周至患者去世或研究完成期间，每12周测定一次。
研究结果：
对于照料者而言，随机化至12周时即刻减延迟的估计治疗效应（平均值[标准误]）为：QOL：-3.1[2.3]，p=0.17；抑郁：-4.1[1.3]，p=0.003；SB：-1.0[0.4]，p=0.02；OB=0.3[0.6]，p=0.60；DB：-0.5[0.6]，p=0.39。干预至12周时的估计治疗效应为：QOL：-6.4[3.4]，p=0.06；抑郁：-7.4[2]，p＜0.001；SB：-1.0[0.6]，p=0.08；OB：-0.6[0.7]，p=0.44；DB：-0.5[0.8]，p=0.50。从患者去世向前逆推的估计治疗效应为：QOL：-4.9[2.6]，p=0.07；抑郁：-3.8[1.5]，p=0.02；SB：-1.1[0.4]，p=0.01；OB：-0.6[0.6]，p=0.26；DB：-0.7[0.6]，p=0.22。
研究结论：
12周之前，即刻组照料者的抑郁及SB水平更低，QOL更高。结果提示，肿瘤姑息治疗应越早越好，以最大程度地为照料者带来获益。
ASCO简评：
PatriciaGanz医生 ASCO大会专家，加州大学洛杉矶分校（UCLA）医学与公共卫生学院
“本项创新性研究体现了为癌症照料者提供支持的需要，以及‘赶早不赶晚’所带来的获益。改善照料者的精神健康及舒适度也是姑息治疗的重要组成部分。”
医脉通整理报道，转载请注明出处。
会议专题》》》2014年ASCO年会专题报道
原文摘要
Abstract #LBA9513: Benefits of immediate versus delayed palliative care to informal family caregivers of persons with advanced cancer: Outcomes from the ENABLE III randomized clinical trial.
Authors: J Nicholas Dionne-Odom, Andres Azuero, Kathleen Lyons, Zhongze Li, Tor Tosteson, Zhigang Li, Jay Hull, Jennifer Frost, Mark Hegel, Konstantin H. Dragnev, Imatullah Akyar, Marie Bakitas; The University of Alabama at Birmingham Comprehensive Cancer Center, Birmingham, AL; The Geisel School of Medicine at Dartmouth, Hanover, NH; Norris Cotton Cancer Center, Lebanon, NH; Dartmouth College, Hanover, NH; Dartmouth-Hitchcock Medical Center, Lebanon, NH
Background: Family caregivers of individuals with advanced cancer experience significant burden and diminished QOL; few interventions have been found to reduce these outcomes.
Methods: Randomized clinical trial conducted from 10/11/2010 to 9/5/2013 of immediate versus delayed (initiated 12 weeks after randomization) entry patients (n=207) and caregivers (n=122) into ENABLE (Educate, Nurture, Advise, Before Life Ends), a phone-based concurrent oncology palliative care intervention. QOL (Caregiver Quality of Life-Cancer, lower scores=better QOL), depression (Center for Epidemiological Study-Depression) and burden (Montgomery Borgatta Caregiver Burden Scale; subjective burden [SB], objective burden [OB]; demand burden [DB]) measures were collected at baseline, 6, 12, 18, and 24 weeks, and every 12 weeks until patient death or study completion.
Results: Estimated treatment effects (immediate minus delayed) for caregivers from randomization to 12 weeks were (mean [SE]): -3.1 [2.3] for QOL (P=.17), -4.1 [1.3] for depression (P=.003), -1.0 [0.4] for SB (P=.02), 0.3 [0.6] for OB (P=.60), and -0.5 [0.6] for DB (P=.39). Estimated treatment effects (immediate minus delayed) from intervention initiation to 12 weeks were (mean [SE]): -6.4 [3.4] for QOL (P=.06), -7.4 [2] for depression (P<.001), -1.0 [0.6] for SB (P=.08), -0.6 [0.7] for OB (P=.44), and -0.5 [0.8] for DB (P=.50). Estimated treatment effects (immediate minus delayed) measured backwards from the time of patient’s death were (mean [SE]): of -4.9 [2.6] for QOL (P=.07), -3.8 [1.5] for depression (P=.02), -1.1 [0.4] for SB (P=.01), -0.6 [0.6] for OB (P=.26), and -0.7 [0.6] for DB (P=.22).
Conclusions: Caregivers in the immediate group had lower depression, SB, and trends towards better QOL in comparisons up to 12 weeks, following initiation of the intervention in both groups, and in the terminal decline analysis. These results suggest that concurrent oncology palliative care should be initiated as early as possible to maximize benefit to caregivers.
