Agresivnost zdravljenja in ostale zdravstvene oskrbe bolnikov z razsejanimi solidnimi raki v zadnjih tednih življenja

Golob, Nena (avtor), Šeruga, Boštjan (mentor)

Uvod in namen: V luči razvijajoče se mreže paliativne oskrbe v Sloveniji smo z raziskavo želeli pridobiti podatke o agresivnosti specifičnega onkološkega zdravljenja in ostale agresivne zdravstvene oskrbe bolnikov z napredovalimi solidnimi raki v zadnjih tednih življenja. Analizirali smo vnaprej definirane kazalnike agresivnega specifičnega onkološkega zdravljenja in ostale agresivne zdravstvene oskrbe v zadnjih tednih življenja ter trend njihovega posluževanja skozi čas. Preučili smo tudi dejavnike, ki so povezani s prejemanjem agresivnega specifičnega onkološkega zdravljenja v zadnjih tednih življenja. Naš namen je bil tudi ugotoviti, ali so bolniki, ki so vključeni v specializirano paliativno oskrbo v zadnjih tednih življenja, manj agresivno obravnavani kot bolniki, ki tovrstne obravnave niso deležni. Metode: Raziskava je zasnovana kot retrospektivna analiza podatkov (obstoječih podatkovnih baz) odraslih bolnikov, ki so se zdravili na Onkološkem inštitutu Ljubljana in so umrli med letoma 2015 in 2019 ter so imeli ob smrti dokazan napredovali solidni rak in stalno prebivališče v Mestni občini Ljubljana ali širši okolici. Obravnavali smo obdobje zadnjih štirih in dveh tednov življenja. Analizo smo opravili na osnovi vnaprej definiranih kazalnikov agresivnega specifičnega onkološkega zdravljenja in ostale agresivne zdravstvene oskrbe. Bolnike smo opredelili še na osnovi sociodemografskih podatkov, vrste raka, prognoze raka in vključenosti v specializirano paliativno oskrbo. Številske spremenljivke smo opisali s povprečjem oz. z mediano ter s standardnim odklonom oz. z interkvartnim razmikom. Kategorične spremenljivke pa smo opisali z ustreznimi frekvenčnimi razporeditvami in grafičnimi prikazi. S pomočjo multivariatne logistične regresije smo ugotavljali povezanost med posameznimi pojasnjevalnimi spremenljivkami (letom smrti, spolom, starostjo ob smrti, vrsto raka, prognozo raka in vključenostjo v specializirano paliativno oskrbo) ter agresivnim specifičnim onkološkim zdravljenjem oz. ostalo agresivno zdravstveno oskrbo ob koncu življenja. Rezultati: V analizo smo vključili 1736 bolnikov; od teh je bilo 868 (50 %) žensk. V času smrti je bila njihova srednja starost 70,4 leta. Prognoza raka je bila ocenjena kot ugodna, srednje ugodna in slaba pri 572 (32,9 %), 424 (24,4 %) in 740 (42,6 %) bolnikih. Med letoma 2015 in 2019 je vsaj eno vrsto agresivnega specifičnega onkološkega zdravljenja prejelo 538/1736 (31,0 %) bolnikov v zadnjem mesecu življenja in 250/1736 (14,4 %) bolnikov v zadnjih dveh tednih življenja. Bolniki so najpogosteje prejemali sistemsko zdravljenje, kjer smo opazili, da se je delež bolnikov, ki so bili zdravljeni s sodobnimi sistemskimi protirakavimi zdravili (tj. tarčnimi molekulami, imunoterapijo in ostalimi biološkimi zdravili), povečal. Na podlagi svojih ugotovitev lahko zaključimo, da so imeli bolniki z vsakim dodatnim opazovanim letom večje obete, da bodo v zadnjih dveh tednih življenja agresivno specifično onkološko zdravljeni (OR 1,14; 95 % CI [1,03 do 1,26], p = 0,009). Dokazali smo še, da so imeli bolniki z vsakim dodatnim letom starosti manjše obete, da bodo prejeli agresivno specifično onkološko zdravljenje (OR 0,96; 95 % CI [0,95 do 0,97], p ? 0,001) in ostalo agresivno zdravstveno oskrbo (OR 0,96; 95 % CI [0,95 do 0,97], p ? 0,001) v zadnjem obdobju življenja. Bolnice z ginekološkimi raki pa so v primerjavi z bolniki z drugimi raki (rakom glave in vratu, germinalnim rakom ter sarkomom) v zadnjem mesecu življenja imele mejno značilno manjše obete za agresivno specifično onkološko zdravljenje (OR 0,53; 95 % CI [0,28 do 1,00], p = 0,05) in manjše obete za ostalo agresivno zdravstveno oskrbo (OR 0,52; 95 % CI [0,28 do 0,97], p = 0,04). Potrdili smo še, da so bolniki, ki so v zadnjem mesecu življenja prejeli agresivno specifično onkološko zdravljenje, imeli večje obete, da bodo deležni tudi ostale agresivne zdravstvene oskrbe (OR 1,84; 95 % CI [1,47 do 2,3], p ? 0,001) in najpomembneje, da je vključitev v specializirano paliativno oskrbo prispevala k manjšim obetom za agresivno specifično onkološko zdravljenje (OR 0,19; 95 % CI [0,12 do 0,31], p ? 0,001 in OR 0,26; 95 % CI [0,13 do 0,50], p ? 0,001) in ostalo agresivno zdravstveno oskrbo (OR 0,25; 95 % CI [0,15 do 0,40], p ? 0,001) bolnikov v zadnjem obdobju življenja. Zaključki: Na podlagi svojih rezultatov smo potrdili, da so bili bolniki med letoma 2015 in 2019 z vsakim dodatnim opazovanim letom bolj verjetno agresivno specifično onkološko zdravljeni v zadnjih dveh tednih življenja. Ugotovili smo zaskrbljujoč časovni trend čedalje pogostejše uporabe sodobnih sistemskih protirakavih zdravil predvsem pri mladih bolnikih. Bolniki, ki so bili vključeni v specializirano paliativno oskrbo, so imeli manjšo verjetnost za prejemanje agresivnega specifičnega onkološkega zdravljenja in ostale agresivne zdravstvene oskrbe v zadnjem obdobju življenja.

• Jezik: Slovenski jezik
• Ključne besede: agresivno specifično onkološko zdravljenje, ostala agresivna zdravstvena oskrba, kazalniki agresivne zdravstvene obravnave, dejavniki za agresivno zdravstveno obravnavo, zadnje obdobje življenja, paliativna oskrba.
• Vrsta gradiva: Doktorsko delo/naloga
• Organizacija: MF - Medicinska fakulteta
• Leto izida: 2024
• PID: 20.500.12556/RUL-165101
• Datum objave v RUL: 23.11.2024

Sekundarni jezik

• Jezik: Angleški jezik
• Naslov: Aggressiveness of cancer treatment and other medical care in patients with metastatic solid cancer near the end of life

Izvleček

Background: In the light of the developing network of palliative care in Slovenia, we wanted to obtain data of the aggressiveness of specific oncological treatment and other aggressive medical care of patients with disseminated solid cancers in the last weeks of life. We analyzed predefined indicators of aggressive specific oncological treatment and other aggressive medical care in the last weeks of life and their use over time. We also examined the factors predicting the odds of recieving aggressive specific oncological treatment in the last weeks of life. Our aim was also to determine whether patients who were included into the specialized palliative care in the last weeks of life were treated less aggressively than patients that were not. Methods: Our research is a retrospective analysis of data (existing databases) of adult cancer patients who were treated at the Institute of Oncology Ljubljana and died between 2015 and 2019 and had proven advanced solid cancer at the time of death and a permanent residence in the Municipality of Ljubljana or its surroundings. We considered the period of the last four and two weeks of life. The analysis was performed on predefined indicators of aggressive specific oncological treatment and other aggressive medical care. Patients were categorized based on sociodemographic data, diagnosis of cancer, prognosis of cancer and involvement into the specialized palliative care. Numerical variables were described by means or medians and by standard deviations or interquartile ranges, respectively. Categorical variables were described with appropriate frequency distributions and graphic displays. Using multiple logistic regression, we assessed the relationship between the explanatory variables (year of death, sex, age at death, cancer prognosis, type of cancer and involvement into the specialized palliative care) and aggressive specific oncological treatment or other aggressive medical care at the end of life. Results: The analysis included 1,736 patients where 868 (50%) were women. The median age at death was 70.4 years. The cancer prognosis was assessed as good, intermediate and poor in 572 (32.9%), 424 (24.4%) and 740 (42.6%) patients. Between 2015 and 2019, 538/1,736 (31.0%) and 250/1,736 (14.4%) patients received respectively at least one modality of aggressive specific oncological treatment in the last month and last two weeks of life. The use of modern systemic anticancer drugs (i.e. small-molecule targeted agents, immunotherapy and other biological agents) increased over time. Overall, in the 5-year long studied period the odds of receiving aggressive specific oncological treatment in the last two weeks of lives were higher with every additional observational year (OR 1.14; 95% CI [1.03 to 1.26], p = 0.009). With every additional year of age patients had lower odds of receiving aggressive specific oncological treatment (OR 0.96; 95% CI [0.95 to 0.97], p ˂ 0.001) and other aggressive medical care (OR 0.96; 95% CI [0.95 to 0.97], p ˂ 0.001) at the end of life. Patients with gynecological cancers had border line significantly lower odds of receiving aggressive specific oncological treatment (OR 0.53; 95% CI [0.28 to 1.00], p = 0.05) and lower odds of receiving other aggressive medical care (OR 0.52; 95% CI [0.28 to 0.97], p = 0.04) in the last month of life as compared to patients with other types of cancer (head/neck cancer, germline cancer and sarcoma). Patients who in the last month of life received aggressive specific oncological treatment had higher odds of receiving other aggressive medical care (OR 1.84; 95% CI [1.47 to 2.3], p ˂ 0.001) and most importantly, the inclusion of patients into the specialized palliative care contributed to lower odds of receiving aggressive specific oncological treatment (OR 0.19; 95% CI [0.12 to 0.31], p ˂ 0.001 and OR 0.26; 95% CI [0.13 to 0.50], p ˂ 0.001) and other aggressive medical care (OR 0.25; 95% CI [0.15 to 0.40], p ˂ 0.001) at the end of life. Conclusions: Based on our results, we did confirm that between 2015 and 2019 patients in the last two weeks of life were more likely to be treated with aggressive specific oncological treatment with every additional observational year. We found a worrying temporal trend of increasing use of modern systemic anticancer drugs, especially among younger patients. Patients who were included into the specialized palliative care were less likely to receive aggressive specific oncological treatment and other aggressive medical care at the end of life.

• Ključne besede: aggressive specific oncological treatment, other aggressive medical care, indicators of aggressive approach, factors for aggressive approach, end of life, paliative care.