| Přispěvatelé: |
University of Helsinki, Faculty of Medicine, Plastiikkakirurgian klinikka, Doctoral Program in Clinical Research, Helsingin yliopisto, lääketieteellinen tiedekunta, Kliininen tohtoriohjelma, Helsingfors universitet, medicinska fakulteten, Doktorandprogrammet i klinisk forskning, Sandelin, Kerstin, Jahkola, Tiina, Roine, Risto P. |
| Popis: |
Breast cancer patients’ health-related quality of life (HRQoL) is an important quality indicator in breast cancer care. HRQoL is recommended to be studied with both generic and disease-specific HRQoL measuring tools. Different techniques in breast cancer surgery affect the patients’ well-being in different ways. Patient-dependent factors and tumour biology both have their impact on treatment choices. Knowledge of breast cancer patients’ HRQoL in relation to different surgical methods is still scarce. The method and timing of breast reconstruction is under debate between immediate breast reconstruction (IBR) and delayed breast reconstruction (DR). Pressure on societies caused by the rising incidence of breast cancer is associated with a need for health-economic evaluations to guide resource allocation on cancer treatment. This thesis evaluates breast cancer patients’ HRQoL in different states of the disease and compares different measuring tools to detect differences between them and produce data on their validity. Different surgical methods to treat breast cancer are studied in relation to HRQoL. All available breast reconstruction methods and the timing of reconstruction are evaluated. The cost of care from the care providers’ perspective is also described during a two-year prospective follow-up. This thesis produces new information concerning HRQoL measuring tools and their usability in breast cancer; how breast cancer treatments performed in Finland affect the patients’ HRQoL and how the costs of different surgical methods are generated. This thesis is based on two study populations. 840 breast cancer patients treated in the Helsinki and Uusimaa Hospital district from 2009 to 2011 were recruited to a cross-sectional observation study as part of a study of prostate, colorectal, and breast cancer patients. Patients filled in an informed consent form and three different HRQoL measuring tools: EQ5D-3L (including VAS), 15D and EORTC QLQ C-30 BR23. Their answers were analysed with linear, stepwise regression analyses. Individual study population of 1065 patients with primary breast cancer were recruited to a prospective study from year 2008 to 2015 in Helsinki and Uusimaa Hospital District. Recruited patients filled in an informed consent form and two HRQoL questionnaires: the generic 15D and breast-cancer specific EORTC QLQ C-30 BR23. The questionnaires were handed out at the first hospital visit and repeated via mail at 3, 6, 12 and 24 months later. Clinical data were collected from hospital records, combined with HRQoL results and then analysed with statistical methods. Data on cost of care were obtained from the ECOMED database, analysed and presented according to the surgical method. EQ5D was associated with a high ceiling effect with 41% of the patients reporting perfect health; other measuring tools performed with less ceiling. Breast cancer patients’ HRQoL deteriorated along the disease progression with patients reporting fatigue, pain and sleeping disorder symptoms. The prospective follow-up included 351 mastectomies, 415 breast resections, 248 oncoplastic resections and 51 immediate breast reconstructions (IBR). 402 patients went through axillary clearance. 840 patients (79% of all) received radiation therapy and 523 (49%) chemotherapy, 766 (72%) patients had endocrine treatment, and 119 (11%) patients had targeted therapy (anti HER2- medication). 41 patients had later corrective surgery and 34 patients had DR. HRQoL was affected by disease status and by the disease burden. Higher Grade, N-class and BMI (body-mass index) correlated with poorer HRQoL at 3 months. The effect of N- and M-class and receiving chemotherapy still correlated with poorer HRQoL at 24 months. Active smoking correlated with complications. Mastectomy patients had the poorest HRQoL throughout the study period and they reported the most pain and arm symptoms. Patients operated on with oncoplastic techniques had the best body image at 24 months. Reconstruction patients had the best physical and sexual functioning scores at 24 months. Reconstruction patients’ recovery after treatments was the slowest. No difference was found between different autologous reconstruction methods. The lowest costs from surgery were observed in BCS patients (mean 6015 euros). Mastectomy was associated with mean costs of 8114 euros, IBR with 18 217 euros, and DR with 19 041 euros. EQ5D-3L is associated with high ceiling effects. Consequently, care must be taken when choosing HRQoL measuring tools. Breast cancer patients frequently reported insomnia, pain and fatigue, indicating the main focus on symptom handling. Mastectomy patients are at risk of poor HRQoL and higher symptom burden. Oncoplastic techniques produce good HRQoL and body image. Breast reconstruction produces good HRQoL, physical - and sexual-functioning scores, but the improvement in HRQoL materialises later than in BCS patients. Breast reconstruction method and timing should be tailored individually, and no patient should be pushed toward reconstruction before being ready for it. The cost difference between IBR and DR is relatively small, so the cost of reconstructive surgery should not be a factor in the decision making. Elämänlaadun arvioiminen on noussut erittäin merkittäväksi tekijäksi arvioitaessa rintasyöpähoitojen vaikuttavuutta ja hoidon laadun tasoa. Rintasyövän leikkausmenetelmä valikoituu syövän biologian sekä potilaaseen liittyvien tekijöiden mukaisesti (rinnan ja kasvaimen koko, terveydentila, toiveet). Tämä väitöskirja arvioi eri elämänlaatumittareiden käytettävyyttä rintasyöpäpotilaiden eri tautitiloissa sekä leikkaustekniikoiden vaikuttavuutta potilaiden elämänlaatuun. 840 rintasyöpäpotilasta rekrytoitiin poikkileikkaustutkimukseen vuosina 2009-2011 Helsingin ja Uudenmaan sairaanhoitopiirin (HUS)alueella. Potilaat vastasivat neljään eri elämänlaatukyselyyn: 15D, EORTC QLQ C-30, EQ5D-3L ja VAS. Potilaat jaettiin kyselyhetkellä vallitsevan tautitilan mukaan neljään eri ryhmään. 1065 uuteen rintasyöpään sairastunutta potilasta 2008-2015 rekrytoitiin seurantatutkimukseen HUS:n alueella. Potilaat täyttivät kaksi elämänlaatukyselykaavaketta: 15D ja EORTC QLQ-C30 BR23. Kyselyt toistettiin diagnoosihetkellä sekä postitse 3, 6, 12 ja 24 kk kuluttua diagnoosista. Potilaat jaettiin ryhmiin leikkausmenetelmän mukaan: rinnan osapoisto, rinnan kokopoisto, rinnan rekonstruktio. Hoitojen kustannustiedot haettiin tietokannoista. Potilaiden vastaukset yhdistettiin syövän hoitotietoihin ja arvioitiin tilastollisin menetelmin. Väitöstutkimus tuottaa uutta tietoa rintasyöpäpotilaiden elämänlaadusta eri tautitiloissa sekä valottaa miten rintasyöpäpotilaan elämänlaatu muuttuu syövän paranemisprosessin aikana. Eri elämänlaatumittareiden laajaa vertailu tuottaa uutta tietoa mittareiden vahvuuksista ja heikkouksista. Leikkausmenetelmien suhteen potilaiden elämänlaatu vaikuttaa olevan paras rinnan osapoistossa. Erityisesti rintaa muovaavia, ns. onkoplastisia tekniikoita käytettäessä potilaiden elämänlaatu ja kehonkuva on paras. Rinnan kokopoisto aiheuttaa eniten elämänlaatua huonontavia oireita. Rintarekonstruktiot tuottavat korkeaa elämänlaatua. Mahdollisuutta rekonstruktioon tuleekin tarjota kokopoistopotilaille. Rintarekonstruktiomenetelmien välillä ei havaittu merkitseviä eroja. Hoidon kustannusten ei tule olla määräävä tekijä valittaessa rintarekonstruktion ajankohtaa tai menetelmää, vaan toimenpiteet ja niiden ajankohta tulee räätälöidä potilaskohtaisesti. Kipu, väsymys ja uniongelmat ovat seikkoja, joihin tulee kiinnittää huomiota rintasyöpäpotilaiden hoidossa ja resurssien kohdentamisessa. |
