上海市医生对癌症疼痛治疗认识的调查

为了了解世界卫生组织推荐的癌痛“三阶梯止痛”方案在上海实施情况,1999年7月－8日对上海市76所医院1415名医生进行癌症疼痛治疗认识的现状问卷调查。调查显示：①上海市85．3％的各科医生对癌症三阶梯止痛方案有所了解,肿瘤科医生这一比例达到94．1％;癌痛控制基本知识的知晓率达到52．5％,肿瘤科医生达到71．7％;临床实践中遵守三阶梯方案的比例各科医生为43．8％,肿瘤科医生为72．5％。②在医生治疗重度癌症疼痛病人时,处方用药最多依次是度冷丁、强痛定针、消炎痛片和吗啡控释片,即释吗啡片列第9位。③影响癌痛充分治疗的不利因素最重要的是“使用阿片类药物的限定过多”。④扩大医务人员对癌痛控制的知识需求普遍存在。结果表明：上海市癌症三阶梯止痛推广工作已取得明显的进展,对医务人员的培训已接近世界卫生组织的目标;鉴于癌痛在上海流行程度,对医务人员的培训覆盖面和培训深度仍有待进一步加深;特别是针对目前度冷丁仍是医生治疗重度癌症疼痛的首选药物、吗啡使用还不够普遍的状况,应制定相应的卫生政策和癌痛控制规划,保证癌症“三阶梯止痛”原则在上海的进一步推广实行。     

上海市肿瘤患者疼痛及治疗情况-2007年调查结果

目的:调查上海市肿瘤患者癌痛特征及治疗情况.方法:对2007年1月-3月在上海市各级医院治疗的1 131例癌痛患者进行癌痛和治疗情况的问卷调查,并对调查结果进行统计分析.结果:患者从发生疼痛至得到治疗的平均时间为4.1个月,60.6%的患者发生疼痛后能在1个月内得到治疗,79.1%的患者认为止痛药是最有效的止痛方法,68.4%的患者治疗疼痛最常就诊的科室为肿瘤疼痛专科.42.4%的患者认为服用止痛药会成瘾,45.9%的患者仅在疼痛时服用止痛药物.81.3%的患者月平均止痛药费用≤400元,71.9%的患者认为目前的止痛药费用基本或者完全可以负担.接受止痛治疗后患者的疼痛程度明显减轻,身体状况明显改善,患者对止痛治疗效果的满意程度与常住地址类型、是否得到及时的药物治疗和药费负担有关.与1999年的调查结果相比较,1次门诊取药量、肿瘤疼痛专科就诊的比率、对止痛药物成瘾性的正确认知比率及按时服用止痛药的比率均明显上升.结论:止痛治疗可有效控制癌痛,患者对止痛治疗较满意,癌痛治疗的宣传教育工作初显成效;但是,患者对止痛药的认知度及获得止痛治疗的便捷性尚需进一步提高,并且需要进一步减轻癌痛患者的医疗负担.     

云南省3331位医师对癌痛控制认识和处理的调查

[目的]了解实施WHO癌痛＂三阶梯止痛指导原则＂以来,云南省医师对癌痛控制的认识和处理情况。[方法]采用中文的ECOG癌痛调查问卷,对3331名医师进行问卷调查。[结果]①对癌痛的认识：大部分医师认为70%以上的癌症患者患有疼痛、患者是癌痛程度的最准确评定者、本单位癌痛控制一般、大多数患者止痛药物用药不足。②不合理处方习惯：21.0%的医师选用哌替定治疗慢性癌痛,44.3%的医师选择按需给药。③麻醉药的＂毒副作用和成瘾＂恐惧：38%的医师担心毒副作用,19.8%担心成瘾而没有根据需要给足剂量。④癌痛知识培训不足：仅7.5%的医师参加过3次以上的培训。[结论]云南省的癌痛控制工作取得明显进展,但离WHO的要求差距仍较大,应加强对医师培训,转变观念,贯彻实施三阶梯止痛原则。     

强阿片类药物治疗癌性疼痛的临床研究

目的:评价强阿片类药物治疗中、重度癌痛的疗效及安全性,探讨镇痛治疗对生活质量和预后的影响.方法:应用强阿片类药物治疗伴有中、重度疼痛的恶性肿瘤患者122例,观察药物荆量、疗效、不良反应及生存期;采用生活质量量表EORTCQLQ-C30(V3.0)中文版评估66例肺癌疼痛患者镇痛前后的生活质量变化,并对不同疼痛程度和不同疼痛缓解程度癌痛患者的预后进行比较分析.结果:使用阿片类药物治疗后,中度、重度疼痛患者疼痛缓解率分别为94.9%和86.7 %;与治疗前相比疼痛程度明显减低,P＜0.05.治疗过程中便秘发生率47.5%、恶心呕吐11.5%、排尿困难9.0%、头晕4.9%.经镇痛治疗后91.4 %的患者生活质量明显改善,尤以失眠改善最为明显.Kaplan-Meier生存分析显示,中度癌痛患者半年总疼痛治疗生存率明显优于重度疼痛者,疼痛程度与生存显著相关,P=0.000.疼痛完全缓解和明显缓解者半年总疼痛治疗生存率明显高于中度和轻度缓解者,疼痛缓解程度与生存显著相关,P=0.003.Cox多因素分析结果显示,疼痛部位和疼痛程度是影响预后的独立危险因素.结论:强阿片类药物治疗中、重度癌性疼痛是安全有效的;它能明显提高癌痛患者生存率、延长其生存期,并能提高肺癌癌痛患者的生活质量.     

穴位埋线配合以痛为腧针刺法治疗癌性疼痛的疗效观察

目的:分析穴位埋线配合以痛为腧针刺法治疗癌性疼痛的临床疗效。方法:将纳入研究的癌痛患者133例,随机分为试验组(穴位埋线配合针刺+三阶梯疗法)72例和对照组61例,疗程10天,观察两组治疗前后的癌痛缓解情况。结果:试验组对轻、中度、重度癌性疼痛的有效率分别为93.33%、82.35%、62.5%;对照组分别为83.33%、61.29%、66.67%;两组总有效率分别为84.72%和70.49%,经比较具有统计学差异(P<0.05)。结论:采用穴位埋线配合以痛为腧的局部取穴针刺法对癌性疼痛有明显的止痛作用,且优于三阶梯的药物止痛效果。     

食管癌患者癌痛情况及护理需求分析

目的对148例食管癌患者疼痛情况及护理需求进行分析,以探讨更好的护理方法。方法对148例食管癌癌痛患者进行问卷调查,获取其疼痛情况及护理需求。结果 148例癌痛患者平均视觉模拟评分法(VAS)疼痛得分(8.0±2.1)分。其中轻度疼痛11例,占7.4%;中度疼痛71例,占48.0%;重度疼痛66例,占44.6%,重度和中度疼痛患者占绝大多数。全组有128例患者自述情绪抑郁或烦躁,占86.5%;110例患者自述影响食欲,占74.3%;103例患者自述影响睡眠,占70.0%。所有患者均需止痛药物治疗,有32例患者认为止痛药物可完全缓解疼痛,占21.6%;105例患者认为止痛药物只能部分缓解疼痛,占70.9%;另有11例患者认为止痛药物完全无效,占7.4%。癌痛患者的健康教育需求,以止痛药物的使用及副作用得分最高,分别为(45.7±5.0)分和(24.5±5.3)分。对环境护理需求中,以大声喊叫和疼痛时希望家属在旁边为最高,分别为(34.0±8.0)分和(28.9±6.9)分。结论癌性疼痛严重影响患者的生活质量,护理应从患者实际需求出发,以针对性的服务满足患者需求。     

穴位埋线配合以痛为腧针刺法治疗癌性疼痛的疗效观察

目的：分析穴位埋线配合以痛为腧针刺法治疗癌性疼痛的临床疗效。方法：将纳入研究的癌痛患者133例,随机分为试验组（穴位埋线配合针刺＋三阶梯疗法）72例和对照组61例,疗程10天,观察两组治疗前后的癌痛缓解情况。结果：试验组对轻、中度、重度癌性疼痛的有效率分别为93.33%、82.35%、62.5%;对照组分别为83.33%、61.29%、66.67%;两组总有效率分别为84.72%和70.49%,经比较具有统计学差异（P〈0.05）。结论：采用穴位埋线配合以痛为腧的局部取穴针刺法对癌性疼痛有明显的止痛作用,且优于三阶梯的药物止痛效果。     

护理人员癌痛知识及态度的调查

癌痛是癌症患者尤其中晚期癌患者重要症状之一。影响癌痛控制是否满意的一个重要因素是进行有关癌痛知识的教育及普及。本文借助世界卫生组织提供的医护人员癌痛知识及态度调查表，采用多中心调查方法，于１９９６年７～８月对６家医院１６６名肿瘤科护士（师）进行了随机调查，结果显示：相当一部分护士缺乏癌痛知识及鸦片类药物临床药理学知识，没有完全掌握世界卫生组织大力倡导的三阶梯药物止痛方法及有关原则。提示我们应加强对护士进行有关癌痛知识及技能的教育及培训。     

癌痛及其对癌症患者生活质量影响的调查

目的　探讨癌痛及其对癌症患者生活质量的影响。方法　应用简明健康状况调查表(SF 36简表 )及简明疼痛调查表 (briefpaininventoryBPI)对 2 0 0例住院患者的癌痛情况、癌痛对其生活质量的影响及癌痛的处理进行系统的调查。结果　 (1)疼痛的发生率为 6 9 0 % ,其中轻度疼痛占2 1.5 % ,中度疼痛占 19.0 % ,重度疼痛占 2 8.5 %。 (2 )中、重度疼痛患者中消化道肿瘤比例较高。 (3)疼痛与疾病分期无关 (P >0 .0 5 )。 (4)疼痛的发生与骨转移的存在密切相关 (P <0 .0 1)。 (5 )无论是轻度、中度还是重度疼痛 ,均严重影响患者的日常生活、情绪、行走能力、工作、睡眠 ,且随着疼痛程度的加重 ,影响也逐渐加深。但在对生活乐趣和社交两方面的影响上 ,中度疼痛和重度疼痛差异无显著性 (P >0 .0 5 )。 (6 )中度疼痛对患者精神状态的影响要早于重度疼痛 ,因此在癌症患者的疼痛达到中度时 ,就应在止痛治疗的同时密切配合对其心理上的治疗 ,以期达到更好的疼痛缓解。 (7)在疼痛处理上 ,未经适当处理的占 41.3% ;在重度疼痛中 ,强阿片类药物应用仅达 5 2 .1% ,与WHO要求的阶梯止痛治疗原则差距较大。结论　疼痛是影响生活质量的一个重要因素 ,而癌痛的治疗尚存在较大差距。要达到WHO提出的到 2 0 0 0年使全世界癌症患者     

癌痛治疗与癌痛患者生活质量的关系研究

目的探讨恶性肿瘤生存者癌痛治疗与生存质量的关系。方法对入选患者给予三阶梯止痛治疗,应用数字评分疼痛分级法及EORTC QLQ-C30问卷调查表分别对止痛治疗前后患者进行疼痛测定及生活质量测定,对结果进行比较分析。结果 （1）使用三阶梯止痛治疗后,中度疼痛缓解率为95.3%,重度疼痛缓解率为85.3%,疼痛总缓解率为88.4%;不良反应主要表现为恶心、呕吐、便秘等。（2）按照三阶梯止痛疗法疼痛治疗后患者生活质量较好,中、重度癌痛患者社会功能、情绪功能、躯体功能、失眠、整体质量均明显改善（P〈0.01）;中度疼痛患者生活质量得分为65.49±8.54,重度疼痛患者生活质量得分33.38±10.67,与治疗前比较差异均有统计学意义（P〈0.01）。结论三阶梯止痛疗法能明显缓解癌性疼痛,有效地提高恶性肿瘤生存者的生活质量。     

Knowledge and attitudes of physicians in Iran with regard to chronic cancer pain.

BACKGROUND AND AIM: The knowledge and attitudes of health care professionals with regard to pain and its impact on the patient are among identified barriers that prevent health care professionals from providing effective treatment for pain. The purpose of the present study was to evaluate knowledge about and attitudes towards cancer pain and its management in Iranian physicians with patient care responsibilities. METHODS: We surveyed 122 physicians in six university hospitals in Tehran. Fifty-five (45.1%) questionnaires were completed. RESULTS: The majority of physicians (76%) recognized the importance of pain management priority and about one half of the physicians acknowledged the problem of inadequate pain management in their settings. Most cited inability to access professionals who practice specialized methods in this field, and inadequate staff knowledge of pain management as barriers to good pain management. A large majority of them expressed dissatisfaction with their training for pain management in medical school and in residency. Furthermore a considerable widespread knowledge deficit among all medical subspecialties and all levels of experience was noted which was significantly more profound in the non-oncologists group and only correlated poorly with number of total treated patients in past 6 months. CONCLUSION: The most significant barrier to the effective management of pain in cancer patients in Iran is deficit in knowledge as identified in this survey. A combination of an active continuing education program on both the international guidelines with routine professional education and dissemination of guidelines is needed to bring about significant improvement in cancer pain control.     

癌症疼痛状况及其治疗情况调查

目的 探讨肿瘤专科医院患者对癌症疼痛知识认知程度和医务人员对癌症疼痛治疗的态度,以及患者回归社区医院后,社区医务人员对癌症疼痛治疗的认识,药品提供的方便程度。方法 采用自行设计的《疼痛调查问卷》,从2009年3月9日—4月9日对130名湖北省肿瘤医院内科住院患者进行问卷调查, 并对回收的120份调查表进行分析。结果 接受调查的肿瘤患者伴有疼痛的占43.3%。调查者接受的止痛治疗方式有药物止痛（59.6%）、理疗（26.9%）和放化疗（13.5%）。规律用药的只占34.6%。通过止痛治疗缓解程度达70%以上的占38.5%,25%的患者缓解程度不足50%。86.5%的调查者认为社区医院不能提供满意治疗。结论 癌症疼痛的止痛治疗尚不能达到控制疼痛的目标,应加强社区医院医务人员关于癌症疼痛规范化治疗的认识,推广WHO三阶梯止痛治疗原则可以使基层医院、社区医院癌症疼痛治疗效果得到改善。     

Oncologists' attitudes toward and practices in giving bad news: an exploratory study.

PURPOSE: To examine the attitudes and practices of oncologists in disclosure of unfavorable medical information to cancer patients. METHODS: A questionnaire was administered to a group of physicians who attended the 1999 Annual Meeting of the American Society of Clinical Oncology. The questionnaire assessed demographic and practice-related information and the frequency of patient encounters in which unfavorable cancer-related information was disclosed. Participants were also asked about difficulties they had when approaching stressful discussions and communication strategies used in giving unfavorable information. RESULTS: The questionnaire was completed by 167 oncologists. Sixty-four percent were medical oncologists. Thirty-eight percent practiced in North America, 26% practiced in Europe, 13% practiced in South America, and 13% practiced in Asia. Participants gave bad news to patients an average of 35 times per month. Discussing no further curative treatment and hospice was reported as most difficult. In disclosing the cancer diagnosis and prognosis, physicians from Western countries were less likely to withhold unfavorable information from the patient at the family's request, avoid the discussion entirely, use euphemisms, and give treatments known not to be effective so as not to destroy hope than physicians from other countries. There was significant variability in opinions regarding the best time to discuss resuscitation, with 18% of respondents believing that it should be done close to the end of life. CONCLUSION: There was significant variability in how physicians approach information disclosure to cancer patients. Factors such as geographical region and cultural and family variables may be important influences in this process.     

Feasibility of quantitative pain assessment in outpatient oncology practice.

PURPOSE: Although physicians view failure to assess pain systematically as the most important barrier to outpatient cancer pain management, little is known about pain assessment in this setting. We sought to determine whether pain is routinely assessed and whether routine quantitative pain assessment is feasible in a busy outpatient oncology practice. PATIENTS AND METHODS: We conducted a pre- and postintervention chart review of 520 randomly selected medical and radiation oncology patient visits at a community hospital-based private outpatient practice. The intervention consisted of training health assistants (HAs) to measure and document patient pain scores by using a visual analog scale. The main outcome measures included HA documentation of patient pain scores, quantitative and qualitative mention of pain in the physician note, and analgesic treatment before and after the intervention. RESULTS: After the intervention, HA documentation of pain scores increased from 1% to 75.6% (P < .0001). Physician documentation increased from 0% to 4.8% for quantitative documentation (P < .01), and from 60.0% to 68.3% for qualitative documentation (not significant). Of all the patients, 23.1% reported significant pain. Subgroups with greater pain included patients actively receiving radiation treatments and patients with lung cancer. Of patients with significant pain, 28.2% had no mention of pain in the physician note and 47.9% had no documented analgesic treatment. CONCLUSION: Quantitative pain assessment was virtually absent before our intervention but easily implemented and sustained in a busy outpatient oncology practice. Pain score collection identified a high prevalence of pain, patient subgroups at risk for pain, and a significant proportion of patients with pain that was neither evaluated nor treated by their oncologists.     

A survey of cancer pain status in Shanghai

This is a multicenter investigational survey conducted in 76 hospitals in Shanghai between July and August 2004. The objective was to investigate the cancer pain status and physicians' pain management capabilities in Shanghai. A total of 923 cancer patients involved in the investigation completed a questionnaire which included general condition, self-assessment of pain and questions of pain control knowledge. The study results were analyzed concerning: reason for cancer pain, type and intensity of cancer pain, treatment methods, patients' understanding of addiction, patients' request for pain treatment, and patients' and physicians' viewpoint on current cancer pain treatment.     

监测-培训-计划策略对癌症疼痛三阶梯治疗干预的影响

目的为了解监测-培训-计划（MTP）策略对癌症疼痛药物治疗干预的影响,推进＂三阶梯止痛＂在珠海地区的实施。方法 2007年4月至2008年1月对珠海市人民医院进行癌症疼痛药物治疗的动态调研及MTP策略干预。结果在干预前实施＂三阶梯止痛＂治疗百分率仅6.7%,给药途径以注射为主,占93.3%,固定时间给药仅占26.7%,没有病历显示进行疼痛评估,指南遵从率差。通过3轮MTP策略干预后,癌症疼痛药物治疗指南遵从率大有提高,效果显著。结论尽管WHO早在20世纪80年代已发布癌症三阶梯止痛治疗原则,我国也在90年代初推行,但是经过将近20年后,笔者所调研的医院对该原则实施情况不容乐观。MTP策略为推进＂三阶梯止痛＂实施的有效方法。     

Free-standing cancer centers: rationale for improving cancer care delivery

Free-standing cancer centers (FSCC) represent a growing trend in cancer care delivery within community practice. The critical components to FSCC are multidisciplinary cancer care, a complete menu of direct care and support services, a commitment to clinical trials and clinical investigation, and a comprehensive program for quality assurance. The advantages of FSCC to the community, to hospital programs, to the practicing surgical, medical, and radiation oncologists, and to the third-party carriers, including health maintenance organizations, are detailed. The development of an FSCC depends on the resolution of issues of (a) competition (between hospitals, hospitals and physicians, therapeutic disciplines, regional comprehensive cancer centers and FSCCs) and (b) concerns about conflict of interest. The ideal model of FSCC may well be represented by the joint venture of community hospital(s) and the community oncologists.     

Oncologists vary in their willingness to undertake anti-cancer therapies

Previous studies have shown that groups of cancer sub-specialists differ in their stated willingness to undergo treatment for diseases lying within their area of expertise. In order to learn whether oncologists feel similarly about other forms of cancer, medical, radiation, and surgical oncologists were asked to fill out a questionnaire indicating whether they would be willing to undergo either chemotherapy or radiation therapy for a variety of common malignancies, or recommend them to a spouse or sibling. Subjects were also asked whether they would undertake an experimental therapy (interleukin-2) for any of three malignancies, or recommend such treatment to a spouse or relative. Fifty-one oncologists (14 radiation oncologists, 14 surgical oncologists, and 23 medical oncologists) were recruited from the staff of four university teaching hospitals. Although they agreed about accepting or declining therapy for some examples, there was considerable heterogeneity in their responses. In only 37% of the 30 cases involving standard therapies did greater than or equal to 85% of the oncologists agree that they would accept or refuse therapy. Only some of the variation of the responses could be attributed to the sub-specialty orientation of the oncologists. Physicians were as willing to recommend standard therapies for themselves as a spouse or sibling. Physicians were also divided in their opinion about whether they would accept a particular experimental therapy if diagnosed with one of three neoplasms. They were significantly more likely, however, to recommend it for a spouse or sibling than to accept it for themselves. Variation in the proportion of patients who receive anti-cancer therapies may relate, in part, to differences in opinion concerning the worth of such therapies among oncologists or primary physicians. This study shows that oncologists are quite heterogeneous with regard to their personal preferences for anti-cancer treatments for a variety of malignancies. Further studies are required to learn if such attitudes (among oncologists or primary physicians) directly affect the administration of such therapies.     

肺癌生存者在医疗机构 社区医疗服务模式下疼痛治疗的疗效及生活质量研究

目的 探讨在医疗机构-社区医疗服务模式下采用羟考酮缓释片治疗肺癌患者中、重度疼痛的临床疗效并分析对其生活质量的影响。方法 对63例肺癌合并中、重度疼痛患者给予羟考酮缓释片镇痛治疗,采用数字评分疼痛分级法（NRS）及EORTC生命质量测量表（EORTC QLQ-C30）分别评估镇痛治疗前、后的疼痛评分及生活质量;患者出院或门诊就诊后转诊至社区服务站,由社区医师继续进行镇痛治疗、心理干预及随访,4周后进行生活质量调查。结果羟考酮缓释片镇痛治疗后,中、重度癌痛的缓解率分别为94.1％、86.2％,总缓解率为90.5％;不良反应主要表现为恶心、呕吐、便秘等,经对症处理后大多数不良反应减轻或消失。镇痛治疗后全组患者的生活质量明显改善,表现为社会功能、情绪功能、躯体功能、角色功能、疼痛、失眠、整体生活质量均改善（P＜0.05）;中、重度癌痛患者镇痛治疗后的整体生活质量评分分别为52.01±10.36和31.61±13.06,均高于治疗前（P＜0.05）。心理干预后中、重度癌痛患者的整体生活质量评分分别为55.17±11.66和33.98±13.56,均高于心理干预前（P＜0.05）。结论 羟考酮缓释片治疗肺癌伴有中、重度疼痛的疗效显著,不良反应少,患者生活质量明显改善。由肿瘤专科医师和社区医师分担的医疗机构 社区医疗服务模式是可行的,在此模式下的综合性心理干预措施能有效改善肺癌患者的生活质量。