医生需了解化疗药物远期效应

美国国立癌症研究所的一项全国性调查显示，许多初级保健医生(PCP)，甚至一些肿瘤科医生，都不了解乳腺癌和结直肠癌4种常用治疗药物的常见远期副作用。

第一作者、美国波士顿哈佛医学院和肯莫尔哈佛前锋医学中心的PCP Larissa Nekhlyudov博士在美国临床肿瘤学会(ASCO)2012年会前新闻发布会上表示，这项名为“医生关于癌症幸存者照护的态度调查”是于2009年由美国国立癌症研究所发起的，向全美具有代表性的1,072名PCP和1,130名只诊治结直肠癌或乳腺癌患者的肿瘤内科医生寄送了调查问卷。

调查结果显示，仅6%的PCP能识别出阿霉素、紫杉醇、奥沙利铂和环磷酰胺的主要远期效应(LE)，而在被调查的肿瘤科医生中有65%能够识别。

Nekhlyudov博士说，在被问及是否在临床实践中遇到过或者在文献中报道过这4种标准化疗药物的5种LE时，95%的肿瘤科医生能将心功能异常识别为阿霉素的LE，而只有55%的PCP能够识别(P<0.0001)。同样，97%的肿瘤科医生能正确地将周围神经病变识别为紫杉醇和奥沙利铂的LE，而在PCP中这一比例分别只有27%和22%(P均<0.0001)。

不过，调查显示部分肿瘤科医生还应该接受更多的继续医学教育。对于与烷化剂环磷酰胺相关的2种LE，即提前绝经和继发性恶性肿瘤，分别只有71%和62%的肿瘤科医生能正确识别，而在PCP中分别只有15%和17%。

大部分肿瘤科医生和PCP都不知道肺纤维化是紫杉醇(分别只有5%和6%；P=0.42) 或者奥沙利铂(分别只有5%和. 9%；P=0.0002)的迟发效应之一。在指出环磷酰胺与肺纤维化的潜在相关性方面，他们回答得稍好(分别为20.6%和13%；P<0.0001)，可能是因为这在文献中有所提及。

校正分析显示，没有经过医学会认证的肿瘤科医生识别出这4种化疗药物的主要LE的能力较低(OR，0.58)。有51%~90%的时间是在照顾患者(OR，1.87)或者90%以上的时间都和患者呆在一起(OR，1.82)的肿瘤科医生识别出这些LE的能力更强。年龄、性别、种族、在美接受培训、执业类型以及非保险患者所占比例均与医生对LE的认知程度无关。

Nekhlyudov博士指出，肿瘤科医生对此认识不够很可能是因为其大多专注于癌症的治疗，直到最近才意识到幸存者照护以及潜在迟发效应的重要性。“意外的是，肿瘤科医生对化疗药物的迟发效应了解得也比较少。鉴于人们越来越重视癌症幸存者的问题，肿瘤科医生应该多储备一些这方面的知识。”

Nekhlyudov博士补充道，在美国总共有超过1,200万名癌症幸存者，研究结果强调了与这些幸存者打交道的所有医生都有必要接受相关的继续教育。“在患者从肿瘤专科转诊至初级保健机构的过程中，PCP应该充分认识到癌症治疗的迟发效应，这样才能更好地识别并解决癌症幸存者可能出现的各种问题。至于癌症幸存者照护计划是否能够达到这样的目的，还有待进一步的评估。

新闻发布会主持人、ASCO主席Michael Link博士说，在儿童肿瘤学中很早就开始强调幸存者照护这个问题，因为这类患者往往更换医生或者成年后就不再看儿科医生，有的甚至会否认自己曾经患过癌症。ASCO以及美国医学研究院等组织最近刚刚发表了一份名为《聚焦转变：从癌症患者到癌症幸存者》(Lost in Transition)的报告，就完善癌症幸存者的转诊程序提出了指导意见，包括提供癌症照护计划。

去年ASCO年会上报告的另一项调查研究表明，PCP对其乳腺癌和结肠癌幸存者照护知识的掌握程度不自信，而且照护这些患者的能力也较差。此外，PCP和肿瘤科医生都认为以PCP为主的照护模式对于癌症幸存者而言并不是最理想的(J. Clin. Oncol. 2011;29[suppl.];abstract CRA9006)。

Nekhlyudov博士将于6月2日5:30 p.m.在ASCO年会上作正式报告。关于论文摘要，可查阅www.abstract.asco.org。

作者声明无相关利益冲突。

 

Many primary care physicians – and even some oncologists – are unaware of common long-term side effects of four widely used breast and colorectal cancer drugs, a national survey by the National Cancer Institute reveals.

Only 6% of primary care physicians were able to identify the main long-term effects (LEs) of doxorubicin, paclitaxel, oxaliplatin, and cyclophosphamide, compared with 65% of oncologists surveyed.

The results are not surprising, but they underscore the need for ongoing education among all physicians who care for the more than 12 million cancer survivors in the United States, lead author Dr. Larissa Nekhlyudov said during a press briefing highlighting research to be presented at the upcoming annual meeting of the American Society of Clinical Oncology (ASCO).

 “These findings emphasize that in the transition of patients from oncology to primary care settings, primary care providers should be informed about the late effects of cancer treatment so that they may be better prepared to recognize and address these among cancer survivors in their care,” said Dr. Nekhlyudov, a primary care physician (PCP) with Harvard Medical School in Boston and Harvard Vanguard Medical Associates in Kenmore, Massachusetts. “Whether this will be achieved with survivorship care plans needs to be evaluated.”

The “Survey of Physician Attitudes Regarding the Care of Cancer Survivors” was launched by the National Cancer Institute in 2009, with one survey mailed to a nationally representative sample of 1,072 PCPs and the other to 1,130 medical oncologists who only cared for patients with colorectal or breast cancer.

When asked to report the five LEs they had observed and/or had seen reported in the literature for each of the four standard chemotherapy drugs, 95% of oncologists identified cardiac dysfunction as an LE of doxorubicin, compared with 55% of PCPs (P less than .0001), Dr. Nekhlyudov said.

Similarly, peripheral neuropathy was correctly identified as an LE of paclitaxel and of oxaliplatin by 97% of oncologists, but by only 27% and 22%, respectively, of PCPs (both P less than .0001).

The survey suggests, however, that some oncologists could also use additional continuing education. Premature menopause and secondary malignancies – two long-term effects associated with the alkylating agent cyclophosphamide – were identified by only 71% and 62% of oncologists, respectively, along with 15% and 17%, respectively, of PCPs.

Oncologists and PCPs mostly missed pulmonary fibrosis as a late effect for paclitaxel (5% and 6%, respectively; P = .42) or oxaliplatin (5% and. 9%, respectively; P = .0002). They did a little better in pointing out a possible association with cyclophosphamide (20.6% and 13%; P less than .0001), which has been noted in the literature, she observed.

Dr. Nekhlyudov suggested that the lack of awareness among oncologists is likely because much of the focus has been on the treatment of cancer, and only recently have physicians become aware of the importance of survivorship and the potential for late effects.

 “While it is surprising that oncologists were not more aware of late effects, I think that as more and more attention is placed on cancer survivorship, oncologists will become more equipped with that information,” she said.

ASCO president and press briefing comoderator Dr. Michael Link said the problem of survivorship has long been recognized in pediatric oncology, where patients frequently relocate, outgrow their pediatrician, or even deny they ever had cancer. Groups such as ASCO and the U.S.-based Institute of Medicine, most recently through its “Lost in Transition” report, have offered guidance for improving transitions among survivors, including the provision of a cancer care plan.

 “I think the need for all of this has been highlighted in this abstract and certainly, it’s a shot across the bow with things that need to be done,” he said.

In adjusted analyses, oncologists who were not board certified were less likely to identify the main LEs for all four drugs (odds ratio, 0.58).Oncologists were more likely to know their LEs if they spent 51%-90% of their time on patient care (OR, 1.87) or more than 90% of their time with patients (OR, 1.82). Age, sex, race, U.S. training, type of practice, and percentage of uninsured patients were not associated with LE awareness, Dr. Nekhlyudov said.

Previous results from the survey reported at last year’s ASCO annual meeting indicated that PCPs had low confidence in their knowledge of breast and colon cancer survivors, and reported low marks for their skills in caring for these patients. In addition, neither PCPs nor oncologists felt that a PCP-led model was ideal for survivorship care (J. Clin. Oncol. 2011;29[suppl.];abstract CRA9006).

Dr. Nekhlyudov will formally present her study at ASCO at 5:30 p.m. June 2. The abstract can be viewed at www.abstract.asco.org.

The authors reported no disclosures.