点击显示 收起
在20万名病患的全国样本中，令人吃惊的是，有11%病患在接受手术治疗初期乳癌时并没有进行淋巴结的评估；建议的临床执业方式可以协助疾病分期以及适当的治疗选择，但研究者表示在照护上有显著的差异，绝大部分是对黑人病患、没有医疗保险的病患、以及那些居住在已知教育程度较低的地区；该研究结果在乔治亚州亚特兰大癌症健康种族与人种差异科学及美国癌症研究学会的医疗服务缺乏会议上报告。
主要作者美国癌症医学会健康服务研究策略主任Michael Halpern医师向Medscpae肿瘤学表示，这是非常令人担忧的，淋巴结的评估对于乳癌照护是非常重要的一部分。
在访谈时，Halpern医师指出，他不相信医师是故意让特定病患不接受照护，但是他强调，这些研究结果可能代表在治疗病患时，医师必须仔细地对所有病患评估治疗的好处与坏处。
研究者们透过国家癌政资料库，这是项由美国癌症医学会及美国外科医学会所共同赞助的医院登录资料库，他们包括所有被诊断罹患初期T1a、T1b、T1c与T2N0乳癌的女性记录。
研究者针对病患种族与人种、保险状况与年龄，对接受淋巴结评估的影响进行研究，他们以复回归逻辑式分析控制其他社经与临床因子。
【非临床因子影响照护品质】
该团队发现，相较于有保险的妇女，没有保险的妇女接受淋巴结评估的比例下降了24%；相较于居住在较高教育程度区域的妇女，住在低教育程度区域的妇女接受淋巴结评估的比例下降了13%，而相较于白人病患，黑人病患接受这项评估的比例则是低了10%。
Halpern医师向Medscape肿瘤学表示，我们对于病患未接受评估的非临床因子数目感到惊讶。
该团队也发现，年龄是决定病患是否接受淋巴结评估最主要的因子；研究者表示，相较于51岁以下的妇女，73岁以上的妇女接受该评估的比例少了三分之二。
但是，Halpern医师表示，他对于这项发现并不感到担忧，考虑到在肿块切除术或乳房切除术时的淋巴结切片评估准则，建议这项评估措施对老年、有其他严重疾病、或是淋巴结状态并不会影响治疗选择的病患来说是非必需的。
Halpern医师指出，这项研究有许多限制，包括资料库的可靠程度，约有25%的癌症病患病不会收纳到国家资料库中，可能会在其他医院的资料库中，因此我们并没有每一位病患的资料，我们也不知道为什么病患未接受淋巴结评估的原因；他附带表示，这是病患自己的决定吗？或是这是来自于外科医师的决定？我们不知道怎样的因子会影响这项决定。
其他研究已经证实照护的差异来自于不同的来源，包括架构上的障碍，例如健康保险、医院的型态、或是临床医师以及病患因素。
Halpern医师表示，这些对我们所观察到淋巴结切除差异是很重要的，我们必须找出为什么这些差异会存在、以及确认每个人都接受到极佳的癌症照护。
研究者表示无相关资金上的冲突。
Breast Cancer Patients Overlooked for Lymph Node Assessment
By Allison Gandey
Medscape Medical News
A startling 11% of those in a 200,000-patient national sample did not receive a lymph node assessment while undergoing surgery for early-stage breast cancer. The recommended practice promotes disease staging and appropriate treatment selection. But researchers report significant disparities in care, predominantly among black patients, those with no health insurance, and those living in areas where residents are known to have less education. The findings were reported in Atlanta at the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved meeting by the American Association for Cancer Research.
"This is very worrisome," lead author Michael Halpern, MD, PhD, strategic director of Health Services Research for the American Cancer Society, told Medscape Oncology. "Lymph node assessment is an important part of breast cancer care."
During an interview, Dr. Halpern said that he doesn't believe physicians are purposely withholding care from particular patients. But, he noted, "these findings may be signaling important barriers that physicians need to take into account when treating patients to make sure they fully communicate the benefits and risks of treatment to all patients."
The investigators used the National Cancer database, a hospital registry jointly sponsored by the American Cancer Society and the American College of Surgeons. They included records for all women diagnosed with early-stage T1a, T1b, T1c, and T2N0 breast cancer.
Researchers explored the impact of patient race and ethnicity, insurance status, and age on their receipt of axillary lymph node assessment. They controlled for other sociodemographic and clinical factors using multivariate logistic regression.
Nonclinical Factors Influencing Quality of Care
The group found that women without insurance were 24% less likely to receive a lymph node assessment than those with private insurance. Women who lived in areas with low levels of education were 13% less likely to have the procedure than those in areas reporting high levels of education. And black patients were 10% less likely to have the procedure than white patients.
"We were really surprised by the number of nonclinical factors associated with patients not receiving an assessment," Dr. Halpern told Medscape Oncology.
The group also found that age was a major factor in determining who received a lymph node assessment. The researchers reported that women 73 years or older were 3 times less likely to receive the procedure than were patients 51 years or younger.
But Dr. Halpern said he was less concerned by this finding, considering practice guidelines for axillary node dissection during lumpectomy or mastectomy surgery suggest the procedure is optional for elderly patients, for those with other serious illnesses, and for patients in whom lymph node results wouldn’t affect choice of therapy.
Dr. Halpern pointed to a number of limitations to the study, including its reliance on a database. "Roughly 25% of cancer patients would not be included in the national data and would be at other hospitals, so we clearly do not have everyone here," he said. "We also don't know why the patients' lymph nodes were not assessed. Was this a patient-driven phenomenon? Or was this coming from the surgeons? We don't know what factors were influencing the decisions," he added.
Other studies have suggested that disparities in care result from different sources, including structural barriers such as health insurance; type of hospital, physician, or clinical factors; and patient factors.
"All of these may be important in the disparities we observed for axillary node dissection," Dr. Halpern said. "We need to find out why these disparities exist and what to do to make sure that everyone is receiving excellent cancer care."
The researchers have disclosed no relevant financial relationships.
The Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved: Abstract A-65. Presented November 28, 2007.