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中华乳腺病杂志(电子版)

中华乳腺病杂志(电子版) ›› 2015, Vol. 09 ›› Issue (04) : 257 -263. doi: 10.3877/cma. j. issn.1674-0807.2015.04.007

论著

知识宣教对乳腺癌患者保留乳房选择影响的前瞻性队列研究
张燕娜1, 孙强1,†(), 周易冬1, 茅枫1, 关竞红1   
  1. 1.100730 中国医学科学院北京协和医学院北京协和医院乳腺外科
  • 收稿日期:2015-03-24 出版日期:2015-08-01
  • 通信作者: 孙强

Influence of cancer education on breast-conserving surgery decision-making of breast cancer patients: a prospective cohort study

Yanna Zhang1, Qiang Sun1,†(), Yidong Zhou1, Feng Mao1, Jinghong Guan1   

  1. 1.Department of Breast Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
  • Received:2015-03-24 Published:2015-08-01
  • Corresponding author: Qiang Sun
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张燕娜, 孙强, 周易冬, 茅枫, 关竞红. 知识宣教对乳腺癌患者保留乳房选择影响的前瞻性队列研究[J/OL]. 中华乳腺病杂志(电子版), 2015, 09(04): 257-263.

Yanna Zhang, Qiang Sun, Yidong Zhou, Feng Mao, Jinghong Guan. Influence of cancer education on breast-conserving surgery decision-making of breast cancer patients: a prospective cohort study[J/OL]. Chinese Journal of Breast Disease(Electronic Edition), 2015, 09(04): 257-263.

目的

探讨术前乳腺癌保留乳房相关知识宣教对可保留乳房乳腺癌患者手术方式选择的影响。

方法

对2011年5月至11月北京协和医院乳腺外科收治的282 例乳腺癌患者进行保留乳房相关知识宣教并进行问卷调查。 比较保留乳房知识宣教前后保留乳房选择比例的变化,分析保留乳房组与全乳切除组手术方式选择的影响因素。 患者年龄比较采用t 检验,例数比较采用χ2 检验或Mann-Whitney U 检验,多因素分析采用Logistic 回归分析。

结果

知识宣教后,保留乳房选择率由25.2%(71/282)降至19.1%(54/282)(χ2=12.430,P=0.002)。 单因素分析显示:与全乳切除组相比,保留乳房组的平均年龄更低[(51.3±9.9)岁比(42.9±8.2) 岁,t=6.216,P=0.000],受教育水平更高(大学及以上学历的比例:44.9% 比75.0%,χ2=17.925,P=0.000),有职业患者的比例更高(66.3%比85.9%,χ2=9.372,P=0.009)。 家属对手术方式的选择(P=0.001)以及患者在选择手术方式时是否受到家属影响(χ2=7.334,P=0.026)在保留乳房组与全乳切除组间的差异有统计学意义。 多因素分析显示患者年龄(OR=0.907, 95% CI:0.871 ～0.944, P=0.000)和患者家属对手术方式的选择(OR=2.028,95%CI:1.270 ～3.237, P=0.003)是患者保留乳房手术选择的独立影响因素。 患者拒绝保留乳房手术的主要原因是对局部复发的担心(73.5%,150/204);保留乳房失败后患者拒绝乳房再造的主要原因是对再造手术创伤的担心(53.8%,21/39);选择全乳切除患者拒绝再造的两大原因分别为自身对形体改变的良好接受度(47.5%,95/200)以及年龄因素(46.5%,93/200)。

结论

手术方式的决策过程是医师、患者及家属共同参与的过程,医师有必要为可保留乳房乳腺癌患者及其家属提供详尽的手术相关信息,协助患者做出选择。

关键词: 乳腺肿瘤, 乳房切除术, 保留乳房手术, 知识宣教

Objective

To investigate the influence of cancer education on the breast-conserving surgery decision-making of breast cancer patients.

Methods

The cancer education concerning to breastconserving surgery was given to 282 breast cancer patients treated in Department of Breast Surgery, Peking Union Medical College Hospital from May 2011 to November 2011,and then a questionnaire was conducted. All data of the participants were analyzed to compare the proportion of the patients choosing breast-conserving surgery before and after cancer education and detect the factors influencing the surgical choice in breastconserving group and breast resection group. The patients' ages were compared using t test. The numeration of cases were evaluated using χ2 test and Mann-Whitney U test. Logistic regression was also used for multivariate analysis.

Results

After cancer education,the proportion of the patients choosing breast-conserving surgery was decreased from 25.2% to 19.1% (χ2=12.430, P=0.002). Univariate analysis showed that compared with breast resection group, breast-conserving group had a younger age [(42.88±8.14) years vs (51.31±9.90)years, t=6.216, P=0.000], higher education level (the proportion of the patients with college degree or above:75.0% vs 44.9%, χ2=17.925,P=0.000) and a higher rate of employment (85.9% vs 66.3%, χ2=9.372,P=0.009). There were significant differences in surgical choice of their family members (P＜0.001)and its influence on patients' decision-making (P=0.026) between these two groups. The multivariate analysis showed that the patients' age (OR=0.907, 95%CI: 0.871 ～0.944, P=0.000) and the family members'influence on patients' decision-making (OR = 2.028, 95%CI:1.270 ～3.237, P = 0.003) were two independent factors influencing the patient's decision-making for breast-conserving surgery. Totally 150 patients refused BCS due to the fear of local recurrence (73.5%,150/204). Twenty-one patients refused breast reconstruction if breast-conserving surgery were not successful because of the trauma of reconstruction surgery(53.8%,21/39). The main reasons for breast resection patients to reject breast reconstruction lied to the acceptance of body image (47.5%,95/200) and patients' age (46.5%,93/200).

Conclusions

The surgical decision-making process requires the participation of the doctors, patients and their family members. It is necessary for the physicians to provide detailed information to breast cancer patients with the breast-conserving probability and their family members and help them to make optimal decisions.

Key words: Breast neoplasms, Mastectomy, Breast conserving surgery, Cancer education
表1 选择保留乳房的影响因素及量化值
变量 量化值
年龄 连续变量
学历 中学及以下=0;中学以上=1
职业 无职业=0;有职业=1;退休=2
家属选择 尊重患者选择=0;建议全切=1;建议保留乳房=2
家属影响 不影响=0;影响=1;意见一致=2
表2 282 例患者的基线特征
特征 例数 百分比(%)
婚姻状态
已婚 265 94.0
未婚 9 3.2
离异 8 2.8
受教育程度
研究生 9 3.2
大学 136 48.2
高中 119 42.2
小学及以下 18 6.4
医疗保险
有 241 85.5
无 41 14.5
居住地
北京 155 55.0
其他 127 45.0
户籍
城市 254 90.1
农村 28 9.9
表3 282 例乳腺癌患者保乳知识宣教前后手术方式的选择变化
知识宣教前 知识宣教后 合计
全乳切除 保乳 不确定
全乳切除 125 4 11 140
保乳 15 44 12 71
不确定 41 6 24 71
合计 181 54 47 282
表4 全切组与保乳组的乳腺癌患者特征比较
特征 全切组(n=214) 保乳组(n=64) χ2值 P值
例数 构成比(%) 例数 构成比(%)
年龄
≤45岁 57 26.6 38 59.4 23.475 0.000
＞45岁 157 73.4 26 40.6
婚姻
单身或离异 11 5.1 6 9.4 1.536 0.216
已婚 203 94.9 58 90.6
居住地
北京 114 53.3 37 57.8 0.409 0.522
其他 100 46.7 27 42.2
学历
中学及以下 118 55.1 16 25.0 17.925 0.000
大学及以上 96 44.9 48 75.0
职业
有 142 66.3 55 85.9 9.372 0.009
无 32 15.0 5 7.8
退休 40 18.7 4 6.3
医疗保险
有 179 83.6 58 90.6 1.909 0.167
无 35 16.4 6 9.4
理解保乳知识
无需帮助 118 55.1 31 48.4 0.890 0.345
需医师帮助 96 44.9 33 51.6
家属选择
全乳切除 92 43.0 2 3.1 0.001a
保乳 2 0.9 18 28.1
尊重患者选择 120 56.1 44 68.8
受家属影响
是 31 14.5 18 28.1 7.334 0.026
否 67 31.3 13 20.3
二者一致 116 54.2 33 51.6
表5 乳腺癌患者保乳选择相关因素的多因素分析
影响因素 B值 标准误 Wald值 P值 Exp(B) 95%CI
年龄 -0.098 0.021 22.594 0.000 0.907 0.871～0.944
学历 0.440 0.348 1.601 0.206 1.553 0.785～3.070
职业 0.503 0.378 1.772 0.183 1.654 0.788～3.470
家属选择 0.707 0.239 8.770 0.003 2.028 1.270～3.237
家属影响 0.072 0.188 0.149 0.700 1.075 0.744～1.553
图1 选择全乳切除的乳腺癌患者拒绝保乳的理由
图2 乳腺癌患者拒绝乳房再造的理由
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