| Purpose:The treatment of malignant tumor is divided into antitumor treatment and palliative treatment,which purposes are to prolong the survival time and maintain the quality of life.In the course of long-term cancer treatments,we recognize that two kin-ds of treatment adaption should be selected rationally to improve the effective utilizat-ion of medical resources so as to maximize clinical benefits of patients.However,it is a difficult choice to choose palliative treatments in the late stage of the tumor to ente-r the stage of palliative treatment of the tumor smoothly,compared with the early an-d middle stage of the tumor,and the cognitive differences between doctors,patients a-nd family members are important factors.We hope that by understanding the expectati-ons of the cancer treatment targets and the practical understandings of the treatment of tumor in late tumor patients' families,and through the clinical features,treatment c-ontents and clinical benefits of the death patients to establish the palliative treatment limit for advanced cancer patients within weeks before death.Radical palliative treatment programs such as palliative antitumor treatment and best support treatment should n-ot be carried out within the limits,and hospice care should be used to improve the quality of life of the patients and their families to reduce the economic burden and sa-ve medical resources.Material and method: 1.The first part of this study was to study the treatment needs of advanced cancer pat-ients with family members,carried on the investigation to the advanced families of c-ancer patients what kind of treatment would be desired by the family members during hospitalization?The factors affected the patients themselves and their family members to make these treatme-nt expectations as well as family members' first consideration f-actors for hospitalized patients to explore the degree of understanding of palliative car-e for family members of advanced patients in our department.Investigated the family members of advanced malignant tumor patients that received hospitalization for the firs-t time in our department,and the proportion of patients with family members was 1:1 in the first three days of admission.Used percentage method to describe each index,used SPSS20.0 to carry out statistical analysis.For quantitativ-e data,t test was applied to normal test,rank-sum test was used if it was not conformed to normal test,unord-ered R*C table data used chi 2 test,unidirectional ordered R*C table data used Mann-whitney U test,correlation analysis used logistic regression analysis.The main contents of the investigation included two parts:1.Demographic information about family members:Age?sex?etc.2.The choice tendency of family members and the primary co-nsiderations for the treatment of the present patients:1.Prolongation of life?2.Mass r-eduction?3.T-he symptom relieving?4.The size of the side effects?5.The economic f-actors,also we coll-ected the background information of patients:in the age of patien-ts,the ECOG score of patients,etc.2.The second part of this study was to analyse the advanced cancer patients who died in our department,and explored the treatment and influencing factors of these dead pa-tients,then analysed the measures of palliative treatment of dead patients 2 months b-efore death.By using the electronic medical record system in our hospital retrospectively retrieving and screening advanced malignant tumor patients who died in our depa-rtment recording related information including admission age?sex?admission KPS sco-re?etc of patients.Epidata3.1 was utilized to build data base.Data analysis was performed by SPSS20.0 software,descriptive statistics analysis was used.For quantitative dat-a,t test was used for normal test or approximately conforming to a normal test.Chi 2 test was used for qualitative data and unordered R*C table data.3.The third part of this study was further to study blood routine,liver and kidney fun-ctional tests,partial symptoms and physical signs of advanced patients with malignanc-y from the second part of study to explore the indicators that could predict the survi-val time of advance-d patients in order to further develop a model of palliative treatment for advanced malignant tumors to guide the implementation of palliative treatmen-t for advanced malignant tumors.We continued to record the following information o-n the death of the second part:18 symptoms or signs such as corresponding fatigue?poor appetite ?etc and blood routine,liver a-nd kidney functions,blood sugar,etc.D-ata analysis was performed by SPSS20.0 software,f-or quantitative data,t test was u-sed for normal test or approximately conforming to normal test.Repeated measurement data that conform to normality and homogeneity of variance u-sed repeated measureme-nt variance analysis.The friedman test was used for multiple paired samples that did not conform to a normal test.Wilcoxon symbol rank test was used only for two pairs of paired samples that did not conform to the normality test.For qualitative data,unordered R*C table data,we used chi 2 test.Multifactor analysis used logistic regression to screen related variables.ANN?SVM and decision tree model were used to establish the model of palliative treatment for advanced malignant tumor patients by selected variabl-es and then evaluated the effect of each mode.Results: 1.In the first part,76 families completed the investigation,35 of them wanted to recei-ve the palliative care,41 of them wanted to receive the antitumor therapy.Through si-ngle factor and multiple factors' analysis,the family members' own educational backgr-ound were higher than the college or above,the existence of religious belief and the older the patients were,the higher the current ECOG score were,and the family members tended to choose palliative su-pport,the correlation coefficient between patients' age and ECOG score were-0.087 and-2.644,the advantage ratio OR value of family members' own educational background in college and above and the existence of religi-ous beliefs were 5.591 and 56.252.After further analysis of family members' primary consideration of the patients' current treatments we found that regardless choosing palli-ative support or antitumor treatment the family members' first consideration was to pr-olong the survival period of the patients,accounting for 48.57%(17 cases)and 53.66%(22 cases),respectively.In addition,family members selected the antitumor treatment was more preferential to consider the reduction of mass than members selected the palliative support,24.39%(10 cases)VS0%(0 cases),differences were statistically s-ignifycant.It showed that family members of patients with advanced malignant?the patients' 's age?ECOG score and the family members' beliefs and educational background had i-nfluences in making decisions on choosing treatment options.Regardless of choosing palliative support or antitumor treatment,the primary consideration of family members of the major factors remained the unrealistic goal of prolonging the survival period.In the future,in addition to doctors should know how to choose palliative support or hos-pice care and antitumor treatment on advanced malignant tumor patients,also need to popularize the education of palliative support and hospice care in order to make this i-dea deeply in the heart of the people and promote the further development of palliati-ve support and hospice care in China also improve the quality of life of patients wih advanced malignant tumor and their families.2.In the second part,190 cases of death were conformed to the conditions of entry,t-he proportion of men and women was 57%:43%,the average age of admission was66.15±12.22 years,the number of patients at the age of 61-70 was the most,35.79%(68 cases),88.42%(168 cases)were accompanied by distant metastasis at admission,and 46.32%(88 cases)had previously received various antitumor treatments before admission,it was suggested that most of the malignant tumor patients who died in our hospital were accompanied by di-stant metastasis when they were admitted to hospital,and nearly half of the patients had pa-st experiences in palliative antitumor treatments.Patients admitted to hospital for lung cancer were the most,29.47%(56 cases.The m-ost complication of the hospitalized patient was the pathological effusion,27.37%(52cases)?50 patients were given palliative antitumor treatments after admission to hospit-al,the average age of admission was 60.54±12.82 years,the average KPS score of a dmission was 68.15±9.62 points,46%(23 cases)were men,58%(29 cases)had prev-iously received palliative antitumor treatments.140 patients were given palliative suppo-rt treatments after admission to hospital,the average age of admission was 67.31±11.40 years,the average KPS score of admission was 58.29±10.76 points,60%(84 case-s)were men,42.14%(59 cases)had previously received palliative antitumor treatmen ts.30.71%(43 cases)were accepted by hospital with tumor complications.Differences b-etween two groups of admission age and KPS score were statistically significant.After the related analysis of palliative treatments at the end of two months,the group that combining traditional Chinese and Western medicine with palliative treatment was sign-ificantly lower than the western medicine palliative treatment group in the use of pai-nkillers?blood transfusion?drainage of pathological effusion?sedative drugs and hemo-static drugs,differences were statistically significant.It showed that Most advanced malignant tumor patients who died in our hospital were accompanied by distant metastasis on the admission and nearly half of the patien-ts had previous experience in palliative antitumor treatments.Whether patients with advanced malignant tumors were suitable for treatment of more radical palliative antitum-or treatment was only r-relate to patients' age and admission KPS score,not relate to sex?previous antitumor treatment experience and the tumor complication.The smaller a-ge and higher the admission KPS score of patients was,the more suitable for palliati ve antitumor treatments.In palliative treatments for advanced malignant tumors,the combination of traditional Chinese and western medicine treatment mode could obviously reduce the application of some western medicine treatment methods,reduce the financi-al burden on families and improve the patients' 's quality of life indirectly.3.In the third part,we analysed the changes of advanced blood routine?liver and kidney functions?symptoms and signs in 190 cases of death,it was found that there we-re significant differences between the 2 phases of hospice care period(3 days to 2 w-eeks before death)and the best supportive treatment period(1 months to 2 months b-efore death),the test indicators and symptoms and signs were poor general state,u-rea value and cholinesterase value,which was positively correlated with the poor gen-eral state and urea value and negatively correlated with the cholinesterase value,corr el-ation coefficients were 3.582?0.866?-0.002,and OR values were 35.939?2.377?0.998.Then we put 3 indicators into the ANN mode,the sensitivity was 80.46%,the sp-ecificity was 81.82%,the accuracy rate of positive predictive value was 86%,the accuracy rate of negative predictive value was 74%,the area under the ROC curve wa-s 0.804,we put 3 indicators into the SVM mode,the sensitivity was 80.52%,the specificity was 73.05%,the accuracy rate of positive predictive value was 77%,the ac-curacy rate of negative predictive value was 77%,the area under the ROC curve was0.769,we put 3 indicators into the decision tree model,the sensitivity was 81.70%,t-he specificity was 73.94%,the accuracy rate of positive predictive value was 77%,t-he accuracy rate of negative predictive value was 79%,the area under the ROC curv-e was 0.780.It showed that the test indicators and symptoms and signs that had differences bet-ween the 2 phases of hospice care period(3 days to 2 weeks before death)and the best supportive treatment period(1 months to 2 months before death)were poor gene-ral state,urea value and cholinesterase value,patients with poor general condition,t-he greater the value of urea and the smaller the value of cholinesterase were the mor-e likely the patient was in the death bed care period,we should choose hospice care for palliative treatment,on the other hand,the more likely it was to be in the best s-upport period,so the best support treatment should be our first choice.The models of ANN,SVM and decision tree based on the three indexes of poor general state,urea value and cholinesterase value showed good sensitivities and specificities,and the accu-racies of positive and negative predictive values,by comparing the area under the RO-C curve,the ANN model was superior to the other two models,it indicated that the-se three indicators could predict the survival time of patients with advanced malignan-t tumor,and then guide the formulation of palliative treatment for advanced malignan-t tumor.Conclusion: 1.The research on the treatment of malignant tumors is progressing rapidly with more and more therapeutic method is used in clinical.Some methods,such as targeted therap-y,it hasa fuzzy periodic boundary of application,there are also many minimally inva-sive/invasive treatments that can be used in the middle and late stages.However the d-eath of patients with advanced malignant tumor is inevitable,although a part of the patients' families refuse further antitumor treatment,they still expect to prolong their s-urvival,if the doctor caters to this request,excessive medical treatments are inevitabl-e in final stage,so it has a clinical practical significance for both doctors and patient-s to establish a prediction model for advanced palliative treatment.2.By using retrospective studies of dead patients,we screen out the three most relevan-t indicators:general state difference,urea value,cholinesterase value.According to dea-th related indicators,we establish a prediction model of ANN of advanced palliative treatment.This model shows that it can be used to determine the advanced of the terminal treatment stage in patients with advanced cancer in order to avoid excessive me-dical treatment. |
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