Patient- and Tumor-Level Factors Impacting Chemotherapy Use and Effectiveness

Olsson, Linnea Teresa The University of North Carolina at Chapel Hill Pr 2023 해외박사(DDOD)

Background: Chemotherapy efficacy is determined in clinical trial settings, which have limited representation of Black women. In clinical practice, there is more variation in how chemotherapy regimens are assigned and whether they are completed. Identifying factors related to chemotherapy receipt and cessation, as well as factors across which chemotherapy effectiveness may vary, may help to improve clinical outcomes among breast cancer patients.Methods: This project had three primary goals: 1) to describe real-world patterns of chemotherapy receipt and regimens in a diverse population of women with incident breast cancer, 2) to identify factors associated with cessation of chemotherapy, and 3) to explore the relationship between tumor biological characteristics and recurrence within chemotherapy treatment groups.Results: In Aim 1, both clinical characteristics and younger age at diagnosis were strongly associated with receipt of any chemotherapy and with receipt of anthracycline-inclusive regimens. There was not strong evidence of a relationship between race and receipt of chemotherapy. Next, an association was observed between both adjuvant and neoadjuvant chemotherapy regimens and early cessation of chemotherapy. There was also evidence that side effects were strongly associated with cessation of adjuvant chemotherapy. Within patient- and tumor-level characteristics, associations between these factors and cessation varied by chemotherapy regimen. Cessation of chemotherapy was associated with more breast cancer recurrence after treatment. In Aim 2, chemotherapy regimens were associated with recurrence. In unadjusted models, taxane-based treatment was associated with lower recurrence; however, after adjustment for features of disease aggressiveness, this relationship shifted and taxane-based treatment was associated with increased recurrence. Biological factors associated with DNA damage repair (p53, homologous recombination deficiency) were predictive of recurrence among women receiving anthracycline-inclusive regimens, but not among women receiving taxane-based regimens. The prognostic value of Ki-67 status did not vary by chemotherapy regimen.Conclusions: Chemotherapy receipt and cessation vary by some demographic characteristics. Effectiveness of chemotherapy may vary by adherence to treatment and by biological characteristics of the tumor.

급성 골수성 백혈병 환자의 관해유도 요법과 공고 요법 후 발생한 균혈증에 대한 비교 분석

박영은 부산대학교 대학원 2007 국내석사

배경 : 급성 백혈병 치료에 있어 호중구 감소로 인한 감염증은 가장 중요한 합병증 중의 하나로, 이러한 환자들에서 발생하는 균혈증은 내인성 감염(endogenous)이 주요 원인이다. 호중구 감소성 발열 환자의 치료로서 신속한 경험적 항생제 투여가 중요하며, 치료에 따른 균상에 변화가 있다면 경험적 항생제의 선택에도 변화가 필요할 것이다. 본 연구는 급성 골수성 백혈병 환자들 중에서 관해유도 요법과 공고 요법 후에 발생하는 호중구 감소성 발열 환자를 대상으로 각 치료 주기에 따른 균혈증의 차이에 대하여 분석하였다. 방법 : 부산대학교병원 혈액종양내과에서 2005년 1월부터 2006년 12월까지 골수 천자 및 조직 검사를 통하여 급성 골수성 백혈병으로 진단되어 표준 항암 요법을 받은 환자를 대상으로 하여 후향적으로 의무기록을 분석하였다. 환자는 관해유도 요법군과 공고 요법군으로 나누었고, 각 시기에 발생한 호중구 감소성 발열 시에 시행한 혈액 배양 검사에서 분리된 균주들을 조사하였다. 결과 : 급성 골수성 백혈병으로 입원하였던 환자는 72명이었고, 이 중 관해유도 요법을 시행 받은 환자가 58명이었으며, 공고 요법을 시행 받은 환자가 48명이었다. 환자의 평균 연령은 47세(18세-75세), 남녀 비는 5:4 였다. 호중구 감소성 발열은 총 156례였으며 그 중 총 60례(38.5%)에서 균이 분리되었다. 그람 음성균 36례(61%), 그람 양성균 23례(39%), 진균 1례(2%) 순으로 그람 음성균이 가장 많이 배양 검출되었다. 관해유도 요법과 공고 요법 중 혈액 배양 검사 양성은 각각 58례 중 30례(51.7%)와 103례 중 29례(28.2%)로 나타났다. 관해유도 요법과 공고 요법 후 분리된 균주를 비교해 보면, 그람 양성균과 그람 음성균의 비에 유의한 차이를 보였다. 결론 : 본 연구에서는 항암 화학요법 주기에 따라 호중구 감소성 발열 환자의 혈액 배양에서 분리되는 원인균에 유의한 차이가 있음을 보여 주었고, 그 원인으로는 중심 정맥 도관의 유치, 항암 화학요법 약제의 종류와 용량, 예방적 항균제의 사용 등으로 생각해 볼 수 있다. 본 연구의 결과는 급성 골수성 백혈병 환자에서 감염 부위를 알 수 없는 호중구 감소성 발열이 발생하였을 때 각 항암 요법 주기별로 발생할 수 있는 흔한 원인 균주에 대하여 적절한 경험적 항균제를 선택하는데 도움이 될 것으로 생각된다. Background: Despite the recent advance in chemotherapy and supportive care, infection remains one of the major complications in the patient with acute leukemia. Disruptions of the mechanical defense barriers of skin and mucosae, secondary to chemotherapy, lead to increased exposure to potential microorganisms, which can cause fever and infection. The purpose of this study is to determine the patterns and trends of bacteremia in patients undergoing chemotherapy for acute leukemia and to find out the differences in the bloodstream isolates of each chemotherapy group. Methods: The medical records of patients with acute myeloid leukemia from january 2005 to december 2006 were reviewed retrospectively. Data were analyzed to compare the bloodstream isolates of induction chemotherapy group to consolidation chemotherapy group. Results: Out of total 72 cases, 58 cases received induction chemotherapy and 48 cases received consolidation chemotherapy at least one more time. One hundred and fifty six neutropenic fever occured. Sixty cases (bacteria: 59 cases, fungus: 1 case) were isolated from blood cultures. From bacteria isolates, 61% were Gram-negative organisms and 39% were Gram-positive. In the induction chemotherapy group, the bacteria was isolated in 30 cases (Gram-positive: 55% vs Gram-negative: 45%) out of 58 neutropenic fever events. In the consolidation chemotherapy group, the bacteria was isolated in 29 cases (Gram-positive: 23% vs Gram-negative: 77%) out of 103 neutropenic fever events. The incidence of Gram-positive and Gram-negative bacteremia differed significantly between the cycles of chemotherapy. Conclusion: The patterns of bacteremia between induction and consolidation chemotherapy group are different and have been influenced due to many factors. Appropriate selection of empirical antibiotic therapy according to the cycles of chemotherapy plays important role in an effective prevention and treatment of severe neutropenic fever for the patients with acute myeloid leukemia.

Morphologic alteration of metastatic neuroblastic tumor in bone marrow after chemotherapy

배고은 성균관대학교 일반대학원 2014 국내석사

Background: The aim of this study is to evaluate the histologic features of metastatic neuroblastic tumors (NTs) in bone marrow (BM) before and after chemotherapy in comparison with those of primary NTs. Method: A total of 294 biopsies from 48 children diagnosed with NTs with BM metastasis were examined. There were 48 primary neoplasm biopsies, 48 BM biopsies before chemotherapy, 36 primary neoplasm excisional biopsies after chemotherapy, and 162 BM biopsies after chemotherapy. Results: Metastatic NTs in BM before chemotherapy were composed of undifferentiated and/or differentiating neuroblasts, but had neither ganglion cells nor Schwannian stroma. Metastatic foci of BM after chemotherapy differentiated into ganglion cells or Schwannian stroma, which became more prominent after further cycles of chemotherapy. Persistence of neuroblastic tumors or tumor cell types in BM after treatment did not show a statistically significant correlation with patient outcome. However, three of five patients with newly developed, poorly differentiated neuroblasts in the BM after treatment died due to disease progression. Conclusion: Metastatic NTs in BM initially consist of undifferentiated or differentiating neuroblasts regardless of the primary tumor subtype and become more differentiated after chemotherapy. Poorly differentiated neuroblasts arising newly after treatment might be an indicator of poor prognosis.

Therapeutic outcome of palliative chemotherapy in patients with recurrent hepatocellular carcinoma after liver transplantation

이은영 서울대학교 대학원 2012 국내석사

Background and purpose: For patients with hepatocellular carcinoma (HCC) and liver cirrhosis, liver transplantation can be an effective treatment option for cure. However, substantial number of patients have recurrence of HCC and the prognosis is grave. The purpose of this study is to evaluate efficacy and safety of palliative chemotherapy. Methods: 66 patients who received chemotherapy for recurrent HCC after liver transplantation between 2004 and 2011 were retrospectively reviewed with their electronic medical records. Chemotherapy regimens, the survival time and associated treatment options were analyzed. Results: Overall response rate to chemotherapy was 16.7%. The median progression free survival (PFS) from the first chemotherapy was 2.0 months (95% CI 1.682-2.318) and the median overall survival (OS) was 11.6 months (95% CI 7.802-15.476). Patients with LN metastasis at the initial diagnosis of recurrence had the shortest overall survival (3.1 months, p=0.005). PFS of four most common chemotherapy regimens were 1.9 months in TS1/cisplatin (n=11), 2.0 months in capecitabine/cisplatin (XP, n=10), 2.3 months in 5-fluorouracil/cisplatin (FP, n=16), and 1.8 months in sorafenib (n=21). Patients used sirolimus as an immunosuppressive agent showed a 3 month-longer survival than the others (p=0.167). Regarding chemotherapy toxicities, eight patients (12.12%) had grade 3-4 neutropenia and 2 (3.03%) experienced neutropenic fever. Three patients (4.54%) had grade 3-4 anemia and 5 (7.57%) had grade 3-4 thrombocytopenia. Grade 3-4 non-hematological toxicities were nausea, vomiting for one patient (1.51%), stomatitis (1.51%), aminotransferase elevation (1.51%), hyperbilirubinemia (1.51%), and azotemia (1.51%). Conclusion: The result of this study could be concluded that systemic palliative chemotherapy is feasible and tolerable for patients with recurrent HCC after liver transplantation. More investigations are needed to establish effective chemotherapeutic strategies for this group of patients. Key words: Hepatocellular carcinoma, liver transplantation, chemotherapy, recurrence 서론 : 간세포암과 간경변을 지닌 환자의 치료 수단 중 하나인 간이식은 완치를 기대할 수 있는 효과적인 치료 방법이다. 그러나 간이식을 받은 환자 중 상당수에서 간세포암이 재발하는 것으로 보고 되었으며, 재발한 간세포암의 예후는 매우 좋지 않은 것으로 알려져 있다. 이에 간이식 후 재발한 간세포암에 대해 고식적 항암화학요법의 효능과 안전성을 평가하여 생존 기간에 대한 영향 인자를 규명하고자 한다. 방법 : 2004년부터 2011년까지 간세포암에 대한 치료로 간이식을 받은 환자들 중 간세포암이 재발하여 항암화학치료를 받은 66명의 환자를 대상으로 연구를 시행하였다. 후향적으로 전자의무기록을 조사하여 각 환자의 치료 방법과 생존 기간을 분석하였다. 결과 : 간이식 후 재발한 간세포암 환자에서 항암화학치료의 전체 반응율은 16.7%였다. 질병무진행 생존기간의 중앙값은 2.0개월 (95% 신뢰구간 1.682-2.318)였으며 전체 생존기간의 중앙값은 11.6개월 (95% 신뢰구간 7.802-15.476)이었다. 처음 재발이 진단되었을 때에 림프절 전이가 동반되어 있는 경우 타 장기 전이가 동반되어 있는 경우에 비해 가장 전체 생존기간이 짧았다. (3.1개월, p=0.005) 항암화학요법 중 가장 빈번하게 사용된 4가지 요법에서의 질병무진행 생존기간을 비교 결과, TS-1/cisplatin (n=11) 군에서 1.9개월, capecitabine/cisplatin (n=10) 군에서 2.0개월, 5-fluorouracil/cisplatin (n=16) 군에서 2.3개월, sorafenib (n=21) 군에서 1.8개월이었다(p=0.78). 간이식 후 sirolimus 면역억제제를 사용한 경우 생존기간이 3개월 연장된 결과를 나타내었다(p=0.167). 항암화학요법과 관련된 부작용으로는 8명(12.12%)의 환자에서 3등급 이상 호중구감소증이 나타났으며 2명은 호중구감소성 발열을 겪었다. 3등급 이상 빈혈과 혈소판감소증은 각각 3명(4.54%)과 5명(7.57%)에서 나타났다. 3등급 이상의 비혈액학적 독성은 구역, 구토, 구내염, 아미노전이효소 상승, 고빌리루빈혈증, 질소혈증이었으며 각각 1명(1.51%)씩 발생하였다. 결론 : 간세포암에 대한 치료로 간이식을 받은 환자들 중 간세포암이 재발한 환자들에서 고식적 항암화학요법의 시행은 안전하였다. 항암화학요법 별로 질병무진행 생존기간과 전체 생존 기간의 유의한 차이는 드러나지 않았다. 주요어 : 간세포암, 간이식, 항암화학치료, 재발

Understanding and intervening cancer treatment induced altered appearance and distress among breast cancer patients

강단비 성균관대학교 일반대학원 2017 국내박사

The overall objective of the study is to understand the mechanism of chemotherapy induced skin and hair changes among breast cancer patients and to develop a new intervention to control those symptoms. This study consists of three distinct parts. The first study is a prospective cohort study to evaluate objective changes in water content, sebum content, transepidermal water loss (TEWL), and melanin due to breast cancer chemotherapy, and their association with subjective symptoms. We enrolled 61 patients 18 years of age or older with a postoperative diagnosis of stage I to III breast cancer, who received adjuvant chemotherapy between February and September 2012 at an outpatient breast cancer clinic in Korea. Objective skin parameters, measured using a noninvasive bioengineering device, and patient-reported dryness and dullness were assessed before chemotherapy, after 2 cycles of chemotherapy, and 1, 3, and 6 months after completion of chemotherapy. In this study, we found water content (-6.5%), sebum (-75.5%), and TEWL (-22.4%) significantly decreased during chemotherapy compared to pre-chemotherapy levels (all P values <0.001). These parameters were lowest at 1 month after completion of chemotherapy and recovered thereafter but did not return to baseline levels after 6 months of follow-up. Melanin increased during chemotherapy with respect to pre-chemotherapy levels (8.4%; P <0.001) but decreased from the first month after completion of chemotherapy through the end of follow-up (-17.1 %; P <0.001). The patterns of skin changes were similar in patients with or without hormone therapy. Most of patients reported dryness (57.9%) and dullness (49.1%) after chemotherapy and patient-reported dryness was significantly associated with decreased sebum content. For the second part, we evaluated long-term altered appearance, distress, and body image among posttreatment breast cancer patients and compared them with those of patients undergoing active treatment and with general population. We surveyed 138 breast cancer patients undergoing active treatment and 128 posttreatment patients from 23 Korean hospitals and 315 age- and area-matched general population. We asked the participants recent breast, hair, and skin changes, distress, and body image. Compared to active treatment patients, posttreatment patients reported similar breast changes (6.6 versus 6.2), hair loss (7.7 versus 6.7) and skin changes (5.8 versus 5.4), and both groups had significantly more severe changes than those of general population (P<0.01). For a similar level of altered appearance, however, breast cancer patients experienced significantly higher levels of distress than general population. In multivariable analysis, patients with high altered appearance distress reported significantly poorer body image (-20.7; 95% CI: -28.3 to -13.1) than patients with low distress. Lastly, with the results from the cohort study and cross-sectional survey, we designed a randomized controlled trial to evaluate the efficacy of an oil-based moisturizer in treating chemotherapy-induced skin dryness in breast cancer patients. This trial consisting of three groups: patients using an oil-based moisturizer, those using a general moisturizer (control 1), and those receiving education only (control 2). Breast cancer patients aged between 35 and 65 years expected to receive adjuvant chemotherapy after surgery are eligible for this study. Exclusion criteria include patients with severe skin dryness, atopic dermatitis, psoriasis, or infectious skin diseases prior to chemotherapy. Patients who experience chemotherapy-induced skin dryness after 1 cycle of chemotherapy will be randomly assigned to either an intervention or control group stratified by menopausal status and administration of Herceptin. Patients in the intervention group are supposed to use the oil-based cream twice per day for 1 month after completion of chemotherapy. In the general moisturizer group, patients use general moisture cream of the same colour and texture as the intervention cream, presented in an identical container. Patients in the second control group only receive education material about altered appearance due to chemotherapy and do not receive any moisturizer. The primary outcome is patient-reported chemotherapy-induced skin dryness 1 month after completion of chemotherapy. Secondary outcomes are water content (in arbitrary units, AU) and surface sebum content (µg/cm2) measured by the Multi-Probe Adapter System (Courage-Khazaka, Germany).

Lamivudine prophylaxis for Hepatitis B virus carrier breast cancer patients during adjuvant chemotherapy

이현정 서울대학교 대학원 2012 국내석사

Background: Hepatitis B virus reactivation is well-known complication of cytotoxic chemotherapy in hepatitis B surface antigen (HBsAg) positive cancer patients. Lamivudine was reported to reduce hepatitis B virus (HBV) reactivation during chemotherapy in cancer patients. Our study aimed to describe the temporal trend in HBV surveillance and management during cytotoxic chemotherapy, and to assess the efficacy of lamivudine prophylaxis on hepatic complication in HBsAg positive patients with breast cancer undergoing adjuvant chemotherapy. Methods: Patients with stage 1~3 invasive breast cancer who received curative surgical resection and neoadjuvant and/or adjuvant chemotherapy between 2000 and 2009 were eligible for this study. Patients with positive HBsAg and normal liver function were enrolled. Hepatotoxicity, defined as ALT ≥ 100 IU/mL, and HBV reactivation were compared according to lamivudine prophylaxis. Annual trends in HBV surveillance and use of lamivudine prophylaxis were also reviewed. Results: A total of 165 HBsAg positive patients with breast cancer were enrolled. After the year of 2004, surveillance of HBV infection status and use of lamivudine prophylaxis significantly increased (2.5% vs. 57.6%, p < 0.001). Seventy-three (44.2%) patients received lamivudine prophylaxis and 92 (55.8%) patients did not. Incidence of hepatotoxicity was significantly lower in the prophylaxis group (2.7% vs. 14.1%, p = 0.011). Among the patients with baseline HBV DNA titer available, HBV reactivation rate was lower, without statistical significance, in prophylaxis group (0%) compared to no prophylaxis group (20%) (p=0.104). Lamivudine use was significantly associated with lower rate of hepatotoxicity in subgroup analysis of the patient who received anthracylcine based chemotherapy (2.8% vs. 14.8%, p = 0.013) and glucocorticoids (2.1% vs. 18.6%, p = 0.012). Chemotherapy delays (4.1% vs. 7.6%, p = 0.515) and premature termination of planned chemotherapy (0% vs. 2.2%, p = 0.504) related to hepatic complications did not show statistically significant difference in lamivudine prophylaxis group. Lamivudine withdrawal hepatitis was not detected, but one case of breakthrough HBV reactivation during lamivudine treatment was reported in the present study. Conclusions: Over the past decade, there has been an increase in awareness of HBV reactivation and use of lamivudine during cytotoxic chemotherapy. Lamivudine prophylaxis reduced hepatic complications during adjuvant chemotherapy in patients with breast cancer. Lamivudine prophylaxis should be considered in HBsAg positive breast cancer patients who are candidates of adjuvant chemotherapy. 배경 및 목적: B형 간염 표면 항원 양성인 환자에게 세포 독성 항암 치료를 진행할 때 많이 발생하는 합병증 중의 하나로 B형 간염 바이러스의 재활성화를 들 수 있다. 라미부딘은 이러한 환자들에게 B형 간염 바이러스의 재활성화를 감소시키는 것으로 알려져 있다. 본 연구의 목적은 유방암 항암 치료 시 B형 간염 바이러스 감염에 대한 감시와 예방적 라미부딘 투여의 연도별 변화를 살피고, 예방적 라미부딘의 사용이 B형 간염 표면 항원 양성인 유방암 환자를 대상으로 보조 항암 화학 요법을 시행할 때 간 관련 합병증의 발생에 미치는 영향을 살펴 보는 데 있다. 방법: 2000년부터 2009년까지 근치적 절제술을 받고, 수술 전 항암 화학 요법 및 수술 후 보조 항암요법을 받은 1기에서 3기의 유방암 환자 중에서 정상 간기능을 가진 B형 간염 표면 항원 양성 환자를 대상으로 선정하였다. 간독성은 ALT 수치 100 IU/mL 이상으로 정의하였고, 간독성과 B형 간염 바이러스 재활성화율을 라미부딘 사용 여부에 따라 비교하였다. 연도 별 B형 간염 바이러스 감염 감시 및 예방적 라미부딘 사용 실태에 대하여도 조사하였다. 결과: 2004년 이후, B형 간염 표면 항원 양성인 유방암 환자들을 대상으로 항암 화학 요법 시행 전 B형 간염 바이러스 감염 감시가 증가하였고, 라미부딘의 예방적 사용이 유의하게 증가 하였다 (2.5% vs 57.6%, p<0.001). 총 165명의 대상 환자 중 73명 (44.2%)에서 예방적 라미부딘이 투여되었고, 92명 (55.8%)에서는 투여되지 않았다. 간 독성 발생률은 예방적 라미부딘 투여를 받은 군에서 유의하게 낮았다 (2.7% vs. 14.1%, p=0.011). 항암 치료 전, 기저 B형 간염 바이러스 역가를 측정했던 환자들 만을 대상으로 B형 간염 재활성화율을 보았을 때, 예방적 라미부딘 투여를 받은 군에서 재활성화율은 0%, 그렇지 않은 군에서는 20%로 보고 되었으나, 통계적 유의성은 보이지 않았다 (p=0.104). 안스라사이클린을 포함한 항암 치료를 한 경우 (2.8% vs. 14.8%, p=0.013)와 글루코코르티코이드를 사용한 경우 (2.1% vs. 18.6%, p=0.012) 에서 예방적 라미부딘을 투여했을 때, 유의하게 간 독성의 발생이 감소하였다. 예방적 라미부딘의 사용군에서 간 합병증에 의한 항암 치료의 지연 (4.1% vs. 7.6%, p=0.515) 및 예정된 항암 치료의 조기 종료 (0% vs. 2.2%, p=0.504)가 더 적게 발생하였으나 통계적 유의성은 없었다. 본 연구에서는 예방적 라미부딘 중단 후 간 기능 악화는 보고 되지 않았으나, 라미부딘 사용 중 B 형 간염 바이러스의 재 활성화는 한 예에서 보고 되었다. 결론: 세포독성 항암 치료 중 B형 간염 바이러스의 재활성화의 위험이 증가함에 대한 인식은 점차 증가하고 있으며, 더불어 예방적 라미부딘의 사용도 증가하였다. 예방적 라미부딘의 사용은 B형 간염 바이러스 표면 항원 양성인 유방암 환자에서 보조 항암 치료 시 간 관련 합병증을 감소시켰다. 라미부딘의 예방적 사용은 향후 보조 항암 치료의 대상이 되는 B형 간염 바이러스 표면 항원 양성인 유방암 환자에게 적용되어야 한다.

입원 항암치료와 휴대용 항암제 주입기를 이용한 항암치료에서의 의료의 질과 비용 비교 : 대장암 환자를 중심으로

주은혜 연세대학교 보건대학원 2008 국내석사

This study was done to compare the medical quality and cost between inpatient chemotherapy and ambulatory chemotherapy (portable infusion pump use). This retrospective study was performed between January 2007 and May 2008 at a college hospital in Seoul on 40 colorectal cancer patients who received chemotherapy in administration and on another 40 colorectal cancer patients who received ambulatory chemotherapy (portable infusion pump use).The results are as follows:1. Statistical figures show no notable differences in the common side effects between the use of inpatient and ambulatory chemotherapy.2. Regarding medical treatments outside of prearranged appointments, ambulatory chemotherapy was 7 times more in excess outpatientvisitations and there were no statistical significance for additional emergency visitations.3. Overall satisfaction was higher for ambulatory chemotherapy than inpatient chemotherapy. In comparing the satisfaction rate for people who are in the ambulatory chemotherapy sample group but have also experienced inpatient chemotherapy, the rate of satisfaction is higher for ambulatory chemotherapy.4. The primary factors in influencing the satisfaction rate were the form of medical treatment and the frequency of the chemotherapy treatment.5. On average, inpatient chemotherapy cost 201,122 won more per treatment than ambulatory chemotherapy.6. Comparing the total cost, taking into consideration additional medical, transportation, opportunity, and indirect costs, inpatient chemotherapy cost 333,065 won more than ambulatory chemotherapy.7. In the cost-effect analysis of ambulatory and inpatient chemotherapy, ambulatory chemotherapy dominates the chart with a lower cost and a higher effect (satisfaction rate).The results above show that ambulatory chemotherapy is much more cost effective than inpatient chemotherapy. Therefore the ratio of outpatient chemotherapies and strategic plans should be actively petitioned to the public health policy makers and promoted to the people in order to lower totalmedical costs and effectively improve the level of public health. Furthermore, additional research encompassing sufficient data should be performed on other medical institutions. 입원 항암치료와 휴대용 항암제 주입기를 이용한 항암치료에서의 의료의 질과 비용을 비교하고자 2007년 1월부터 2008년 5월까지 대장암 환자 각각 휴대용 40명과 입원 40명을 대상으로 분석한 결과는 다음과 같다.첫째,항암치료로 인한 공통적인 부작용은 휴대용과 입원에서 통계적으로 유의한 차이가 없었다.둘째,예정된 스케줄 이외 추가의료 이용에 있어 추가 외래 방문율은 휴대용이 7배 더 많았고 추가 응급실 방문율은 통계적으로 유의한 차이가 없었다.셋째,전체 평균 만족도는 입원보다 휴대용이 높게 나타났다. 입원의 경험이 있는 휴대용 항암제 주입기 군에서의 입원과 휴대용의 만족도 비교에서도 휴대용의 만족도가 높게 나타났다.넷째,만족도에 영향을 주는 요인은 의료이용형태,항암치료 횟수였다다섯째,항암치료 1회당 평균비용은 입원이 휴대용 보다 201,122원 더 들었다.여섯째, 추가의료 이용비, 왕복 교통비, 시간 비용의 간접의료비용까지 고려한 총 비용을 비교하면 입원이 휴대용 보다 333,065원 더 들었다.일곱째, 휴대용 항암제 주입기군과 입원 항암치료군의 비용 효과분석에서 휴대용이 입원보다 효과(만족도)는 크고 비용은 적게 소요됨 즉 dominant함을 알 수 있었다.이상의 결과로 휴대용 항암제 주입기를 이용한 항암치료가 입원 항암치료보다 비용 효과적임을 알 수 있었다. 그러므로 외래 base 항암치료에 가산율 등 유인정책을 보건정책에 적극 반영하고 국민에게 홍보함으로써 전체 의료비 절감을 기하고 국민 보건 수준을 보다 효율적으로 향상시킬 수 있을 것이다. 향후 다른 의료기관을 대상으로 충분한 자료를 확보한 추가 연구가 필요하다고 생각된다.

항암화학요법을 받는 암 환자에게 시행한 개별교육이 구내염 예방 및 자가간호수행에 미치는 효과

이명란 연세대학교 대학원 2006 국내석사

본 연구는 항암화학요법을 받는 환자의 구내염 예방에 관한 개별교육을 통해 구내염 발생을 예방하고 자가간호 수행을 높이기 위한 유사실험연구로서 비동등성 대조군 전후시차 설계이다.본 연구의 자료 수집은 2006년 4월 15일부터 5월 30일까지 서울 소재 3차 의료기관인 A 병원 종양내과 환자 중에서 항암화학요법을 받는 암환자를 대상으로 40명을 편의 추출하였다. 이중에 질병의 악화로 3명 탈락, 전원으로 1명 탈락하여 실험군 18명, 대조군 18명을 대상으로 하였다.실험군에게 행한 개별교육은 10분 정도로 항암화학요법 전에 구강관리지침서를 제공하고 설명하였으며 그 내용은 구내염의 정의, 증상, 구내염이 나타나는 시기, 금연, 금주 격려, 식습관과 가글 용법 등의 구강관리 지침으로 교육 시 보호자도 참여시켜 자가 이행을 증진토록 한다. 또한 가글 용액 만드는 방법과 양치질 방법을 시범 보임으로서 자기 효능을 높여 자가간호 수행을 증진시키고 이행토록 하였다.연구도구는 대상자의 일반적 특성 중 심리적 특성으로 자기효능 측정 시 Sherer등(1982)에 의해 개발한 자기효능 척도 중 일반적 자기효능 척도를 오(1993) 가 번역하고 오복자 외(1997)가 수정한 것을 사용하였으며 항암화학요법 전에 설문조사 하였다. 구내염 측정 도구는 University of Nebraska Medical Center(1988)에서 Elier 등이 개발한 구강사정지침 Oral Assessment Guide(OAG)을 이용하여 8개 영역(목소리, 연하, 입술, 혀, 구강점막, 잇몸, 치아/의치)에서 측정하였으며 항암화학요법 전과 항암화학요법 후 5일에서 7일째 사이 그리고 항암요법 14일째 되는 날 측정 하였다. 자가간호 수행은 오복자(1997)가 개발한 자가간호측정도구를 본 연구자가 연구에 맞게 수정, 보완한 도구를 사용하여 항암화학요법 전과 항암요법 14일째 되는 날 측정하였다.자료 분석은 SPSS 12.0 window 프로그램을 이용하여 대상자의 일반적인 특성과 자기효능감을 빈도와 백분율로 나타내었으며 동질성 검증은 Chi-sqaure test로 분석하였고 실험군과 대조군의 구내염 발생에 대한 비교는 Mann-Whitney U test로 분석하였다. 대조군과 실험군의 교육 전후의 자가간호 수행 정도는 paired t-test 로 통계 처리하였다. 또한 도구의 신뢰도는 Cronbach's alpha 로 분석하였다.본 연구의 결과는 다음과 같다.1. 대상자의 인구사회학적 특성 중 성별은 실험군이 남자 50%, 여자 50%였으며 대조군은 남자 83.3%, 여자 16.7%로 대조군이 실험군보다 남자가 더 많았으며 통계적으로 유의한 차이가 있었다(χ2 =4.500, p=.034). 실험군에서 의치가 있는 경우가 22.2%, 대조군에서 72.2%로 실험군 보다 3배 정도 높았으며 통계적으로 유의한 차이가 있었다(χ2 =9.028, p=.030). 성별과 의치유무를 제외한 다른 대상자의 특성은 동질한 것으로 나타났다.2. 항암화학요법 전 구내염이 발생되지 않은 1기는 실험군이 55.6%, 대조군이 44.4%이며, 중등도의 변화를 보인 경우는 실험군이 44.4%, 대조군이 55.6%로 통계적으로 유의한 차이가 없었다(χ2=3.3, p=.495). 항암화학요법 후 5일에서 7일 사이에는 구내염이 발생되지 않은 1기는 실험군이 61.1%, 대조군이 22.2%이며 중등도의 변화를 보인 경우는 실험군이 38.9%, 대조군이 77.8%로 통계적으로 유의한 차이를 보였다(χ2=5.6, p=.020). 항암화학요법 후 14일에 구내염이 발생되지 않은 1기는 실험군이 100.%, 대조군이 33.3%이며, 중등도의 변화를 보인 경우는 실험군이 한 명도 없고 대조군이 66.7%로 통계적으로 유의한 차이를 보였다(χ2=18, p=.001). 따라서 구내염은 항암화학요법 후 5-7일 시점이 가장 심했으며 14일에는 감소되었다.3. 항암화학요법을 하기 전 자가간호 수행 정도를 측정했을 때 실험군 총점의 평균은 29.28점 이며, 대조군은 30.61점으로 대조군의 자가간호 수행 점수가 높았으나 통계적으로 유의한 차이가 없었다(t=.916, p=.372).개별교육을 실시한 실험군은 개별교육 실시 전 29.28점에서 교육 실시 후 34.17점으로 자가간호 수행 정도가 높아졌다. (t=.372, p=.019). 따라서 개별교육이 자가간호 수행에 영향을 미친다.4. 자가간호 수행 정도를 항목별로 개별교육 전과 후를 비교 했을 때 개별교육을 받은 실험군에서 음주습관, 식후 양치질, 취침 전 양치질, 부드러운 칫솔 사용, 가글링, 구강관찰은 개별교육을 통해서 자가간호 수행 정도가 높아졌다.결론적으로 항암화학요법을 받는 환자를 대상으로 한 개별교육이 구내염 예방 및 자가간호 수행을 증진시킬 수 있는 중요한 간호 중재임을 확인 하였다. 따라서 항암화학요법 환자에게 적절한 관리를 할 수 있는 자가간호 수행을 위한 개별교육을 간호 중재로 하는 환자 교육 프로그램의 적극적인 활용이 요구 된다.연구의 제한점으로 대상자의 일반적 특성 중 실험군과 대조군에서 유의한 차이가 있는 성별과 의치 유무는 연구 대상자 숫자의 제한으로 구내염 발생과 자가간호 수행에 미치는 영향을 통계적으로 통제하지 못했다. This is a quasi-experimental study to prevent the occurrence of oral mucositis and enhance the performance of self-care through personal education concerning prevention of oral mucositis for patients receiving cancer chemotherapy and has a nonequivalent control group differential design.40 cancer patients receiving cancer chemotherapy were sampled conveniently from the department of tumor at A Hospital, which is a tertiary medical institution in Seoul, from April 15 through May 30, 2006. With three dropping from a worsened disease and one excluded for the total number of subjects, the experimental and control groups consisted of 18 patients, respectively.The personal education for the experimental group was implemented through explanation with an oral management guide provided about ten minutes before cancer chemotherapy; the guide included definition and symptoms of oral mucositis, time for oral mucositis, encouragement of prohibition of smoking and drinking, eating habits, and gargling, with protectors encouraged to participate in education to enhance self-implementation. How to make a gargle and brush teeth was demonstrated to enhance self-efficacy and thus self-care performance.Oh and other's (1997) revision of Oh's (1993) translation of the general self-efficacy scale, among self-efficacy scales developed by Sherer and others (1982), was used to measure self-efficacy for a psychological characteristic among subjects' general characteristics, along with a survey before cancer chemotherapy. Oral Assessment Guide (OAG) developed by Elier and others at University of Nebraska Medical Center (1988) was used to determine oral mucositis in eight areas―voice, swallowing, lips, oral mucosa, gingiva, teeth, and dentures―before cancer chemotherapy and between five and seven days after cancer chemotherapy and at 14 days. Self-care performance was determined by my revision and complement of the self-care measuring tool developed by Oh (1997) before cancer chemotherapy and at 14th day of the cancer chemotherapy.As for data analysis, an SPSS 12.0 window program was used to determine subjects' general characteristics and self-efficacy at frequency and percentage, along with Chi-square test to analyze homogeneity and Mann-Whitney U test to make a comparison in the occurrence of oral mucositis between the experimental and control groups. Statistical processing was made through paired t-test for the degree of self-care performance before and after education in the experimental and control groups. Reliability of tools was analyzed by Cronbach's alpha.This study obtained the following results.1. As for socio-demographic characteristics, the experimental group consisted of 50% males and 50% females and the control group was composed of 83.3% males and 16.7% females, showing statistically significant differences (χ2=4.500, p=.034). 22.2% had a denture in the experimental group and 72.2% in the control group, showing statistically significant differences with about three times more dentures in the control group than in the experimental group (χ2 =9.028, p=.030). There was homogeneity in all of subjects' characteristics but gender and the presence of dentures.2. Phase 1 without oral mucositis before cancer chemotherapy comprised 55.6% of the experimental group and 44.4% of the control group, with 44.4% of the experimental group and 55.6% of the control group making moderate changes, showing no statistically significant difference (χ2=3.3, p=.495). Phase 1 without oral mucositis between five and seven days after cancer chemotherapy comprised 61.1% of the experimental group and 22.2% of the control group, with 38.9% of the experimental group and 77.85 of the control group making moderate changes, showing statistically significant differences (χ2=5.6, p=.020). Phase 1 without oral mucositis at 14th day of cancer chemotherapy comprised 100% of the experimental group and 33.3% of the control group, with 0% of the experimental group and the 66.7% of the control group making moderate changes, showing statistically significant differences (χ2=18, p=.001). Consequently, oral mucositis was most serious between five and seven days after cancer chemotherapy and decreased at 14 days.3. As for the degree of self-care performance before cancer chemotherapy, the mean of total score was 29.28 for the experimental group and 30.61 for the control group, showing no statistically significant difference (t=.916, p=.372).The experimental group provided with personal education saw their self-care performance improved from 29.28 to 34.17 after the education (t=.372, p=.019). Therefore, personal education has effects on self-care performance in the experimental group.4. After examining the degree of self-care performance before and after personal education by items, the experimental group provided with personal education was found to see their self-care performance improved in terms of drinking habits, teeth-brushing after eating, teeth-brushing before going to bed, use of a soft toothbrush, gargling, and observation of oral cavity.In conclusion, personal education for patients receiving cancer chemotherapy is an important nursing intervention to prevent oral mucositis and improve implementation of self-care. Therefore, personal education to allow cancer chemotherapy patients to implement self-care for proper management requires positive use of patient education programs based on nursing intervention.As limitations of this study, gender and the presence of dentures among subjects' general characteristics with significant differences between the experimental and control groups failed to be controlled statistically in their effects on the occurrence of oral mucositis and performance of self-care due to the limited number of subjects.

Wrist Band를 이용한 내관(P6)지압이 항암 화학요법을 받는 간암 환자의 오심·구토에 미치는 영향

김은주 연세대학교 교육대학원 2007 국내석사

본 연구는 항암화학 치료를 받는 간암 환자를 대상으로 하여 Wrist Band를 이용한 내관(P6) 지압이 항암화학요법 중 오심·구토를 완화시키는 데 효과가 있는지를 검증함으로써 지압의 효과를 확인하고 간암 환자와 다른 암환자의 입원 시 간호 및 퇴원교육을 위한 기초자료로 활용하기 위해 시행되었다.연구 대상자는 서울 시내 대학병원 소화기내과 1개 병동에 항암화학요법을 받기 위하여 2007년 4월부터 5월까지 입원한 간암 환자 16인을 대상으로 하였으며, 대상자를 실험군과 대조군에 각각 한 번씩 속하게 함으로써 최대한으로 동질성을 맞추기 위한 역 처치 전·후 설계를 사용한 실험연구이다.연구 도구는 오심·구토 측정도구인 Rhodes외 2인(1984)이 개발한 INV­2를 Rhodes와 McDaniel(1999)이 수정 보완한 INVR을 김영재외 4인(2000)이 신뢰도와 타당도를 검증하여 한국어로 번역한 INVR을 이용한다.다음은 연구의 결과이다.1) 제 1가설: “항암화학요법을 받는 간암 환자에 있어 내관(P6) 지압군(실험군)은 대조군보다 항암화학요법 주기 3일간 오심 정도가 낮을 것이다”는 지지되었다(z=­3.39, p=0.001).2) 제 2가설: “항암화학요법을 받는 간암 환자에 있어 내관(P6) 지압군(실험군)은 대조군보다 항암화학요법 주기 3일간 헛구역질 정도가 낮을 것이다”는 지지되었다(z=­2.87, p=0.04).3) 제 3가설: “항암화학요법을 받는 간암 환자에 있어 내관(P6) 지압군(실험군)은 대조군보다 항암화학요법 주기 3일간 구토 정도가 낮을 것이다”는 기각되었다(z=­1.30, p=0.208).따라서 본 연구는 표본수가 적다는 제한점을 가지지만 항암화학요법을 받는 간암 환자에게 항암화학요법 중 저녁 식사 1시간 전에 제 1일에 1회, 제2일에 1회, 제 3일에 1회, 양쪽 내관(P6)에 Wrist Band를 이용하여 각각 1시간씩 총 3회 지압을 실시하면 항암화학요법 주기 3일간 오심 및 헛구역질 정도를 감소시키는 효과가 있음을 검증하였다. The objective of this study was to determine and validate the effects of NeiGuan(P6) acupressure by wrist band for relief of nausea and vomiting in liver cancer patients during chemotherapy. The results can be used as basic education material for nursing care for cancer patients both while they are hospitalized and after discharge.The research design was a repeated measure with counterbalancing experimental study. The participants were 16 patients with liver cancer receiving chemotherapy admitted to a major university hospital in Seoul, Korea from April to May 2007. All the 16 participants were treated alternately in both experimental and control group for maximum homogeneity.The primary research tool used was the INVR first developed as INV-2 by Rhodes and orthers (1984) and later adjusted and amended as INVR by Rhodes and McDaniel (1999). It was translated into Korean by YoungJae Kim and others (2000). it had been validated for content and reliability.The outcomes of the study are as follows;1) Hypothesis One that 'patients with liver cancer who receive NeiGuan(P6) acupressure during chemotherapy for the chemotherapy cycle 3 days will experience less nausea than the patients who do not receve NeiGuan(P6) acupressure during chemotherapy' was supported. (z=­3.39, p=0.001).2) Hypothesis Two that 'patients with liver cancer who received NeiGuan(P6) acupressure during chemotherapy for the chemotherapy cycle of 3 days will experience less retching than the patients who do not receive NeiGuan(P6) acupressure during chemotherapy' was supported. (z=­2.87, p=0.04).3) Hypothesis Three that “ patients with liver cancer who received NeiGuan(P6) acupressure during chemotherapyor the chemotherapy cycle of 3 days will experience less vomiting than the patients who receive NeiGuan(P6) acupressure during chemotherapy' was rejected. (z=­1.30, p=0.208).In conclusion despite the limitation of using small sample, this study demonstrates that acupressure treatment by wrist band on both NeiGuan(P6) points located on the forearm, given for patients with liver cancer for 1 hour at a time about half an hour before supper, during the three days of the chemotherapy cycle once on the first day, once on the second day, and once on the third day, is effective in reducing nausea experienced by patients during chemotherapy.

내관(P6) 지압이 항암화학요법을 받는 폐암환자의 오심 구토에 미치는 영향

김영진 연세대학교 대학원 2003 국내석사