《中国肿瘤整合诊治技术指南（CACA）·心理疗法》解读

高质量的肿瘤照护需要以整合理念为基础,将技术干预与人文关怀相结合才能实现对肿瘤患者生存和生活质量的最大程度改善。2023年中国抗癌协会肿瘤心理学专业委员会（CPOS）组织专家编写了《中国肿瘤整合诊治技术指南（CACA）·心理疗法》。本文将对该指南的核心内容进行解读,为临床工作中纳入行之有效的症状管理和心理干预提供实用的实践指导。      

分子靶向治疗:肿瘤治疗的里程碑

在上两个世纪里,肿瘤治疗出现过两次飞跃,一次是Halsted提出肿瘤根治术,另一次是Fish将化学治疗整合于根治术。此后,肿瘤治疗徘徊不前,直到分子靶向治疗出现。分子靶向治疗指使用小分子化合物、单克隆抗体、多肽等物质特异性干预调节肿瘤细胞生物学行为的信号通路,从而抑制肿瘤发展。临床实践证明,分子靶向治疗不仅能"杀灭肿瘤",而且能诱导肿瘤细胞向正常细胞分化而"治愈肿瘤",或通过抑制癌基因信号、延缓肿瘤肿瘤发展而使患者"带瘤生存",在将来有可能将恶性肿瘤转化成类似糖尿病、高血压的慢性病。本文概述了分子靶向治疗的理论基础、标志性成果和发展趋势。     

跨理论模型在喉癌患者术后管理中的应用

目的探讨跨理论模型(TTM)在喉癌患者术后管理中的应用效果。方法采用随机数字表法将150例接受手术治疗的喉癌患者分为干预组和对照组,每组75例,对照组实施常规干预,干预组实施TTM干预。分别采用自制自我管理能力测评量表和中国头颈部癌生命质量测定量表(QLICP-HN)评价干预前(入院时)和干预后(出院6个月后)两组患者的自我管理能力和生活质量,比较两组患者干预后的遵医行为及并发症发生率。结果干预后,两组患者按时服药、健康饮食、症状自处、情绪管理、社交管理评分均高于本组干预前,且干预组患者的上述评分均高于对照组,差异均有统计学意义(P﹤0.05)。干预后,干预组患者中定期复诊、术后接受辅助治疗、进行功能锻炼的比例均明显高于对照组(P﹤0.01)。干预组患者的并发症总发生率明显低于对照组(13.33%vs 33.33%,P﹤0.01)。干预后,两组患者QLICP-HN中躯体功能、心理功能、社会功能和头颈癌特异功能评分均高于本组干预前,且干预组患者的上述评分均高于对照组,差异均有统计学意义(P﹤0.05)。结论TTM干预可有效提高喉癌患者的自我管理能力,强化遵医行为,改善生活质量。     

追踪管理模式对乳腺癌患者心理状态、自我管理能力及生活质量的影响

目的探讨追踪管理模式对乳腺癌患者心理状态、自我管理能力及生活质量的影响。方法根据干预方法的不同,将100例乳腺癌化疗患者分为追踪管理组和常规对照组,每组50例。常规对照组患者予以常规干预措施,追踪管理组患者在常规对照组的基础上予以追踪管理模式干预。比较两组患者的心理状态、自我管理能力及生活质量。结果干预后,追踪管理组患者的焦虑自评量表(SAS)和抑郁自评量表(SDS)评分均低于常规对照组,运动锻炼、认知性症状管理实施、与医师沟通评分均高于常规对照组,躯体功能、角色功能、情绪功能、认知功能、社会功能及总体健康状况评分均高于常规对照组,差异均有统计学意义(P﹤0.05)。结论追踪管理模式能够缓解乳腺癌患者的焦虑、抑郁情绪,提高其自我管理能力及生活质量。     

家属同步健康教育对胰腺癌手术患者治疗依从性及自我管理效能的影响

目的探究家属同步健康教育对胰腺癌手术患者治疗依从性及自我管理效能的影响。方法将150例胰腺癌手术患者按健康教育方式不同分为观察组(72例,实施家属同步健康教育+常规健康教育)及对照组(78例,实施常规健康教育)。比较两组患者干预前及干预3个月后治疗依从性、自我管理效能及生活质量情况。结果干预前,两组患者治疗依从性、自我管理效能、简明健康状况问卷(SF-36)量表各维度评分比较,差异均无统计学意义(P﹥0.05);干预后,两组患者治疗依从性、自我管理效能、SF-36量表各维度评分均增加(P﹤0.05),且观察组各维度评分均高于对照组(P﹤0.05)。结论家属同步健康教育对胰腺癌手术患者治疗依从性及自我管理效能的提高有促进作用,还能改善患者生活质量。     

肿瘤恶液质的诊治

肿瘤恶液质是以肿瘤患者骨骼、内脏的肌肉消耗为特征,伴或不伴有食欲减退、厌食、饱胀感、体重下降、肌肉萎缩、乏力、贫血、水肿、低蛋白血症等一系列临床并发症。肿瘤恶液质的存在使患者的抗肿瘤治疗难以进行,影响患者生存;同时临床并发症的出现也严重影响了患者的生活质量。临床中,肿瘤患者恶液质的发病率高,死亡率高,而且一旦进入恶液质期难以逆转。因此早期发现、早期干预才能改善体重、防止肌肉丢失、减轻恶液质的相关症状,以达到提高生活质量、延长生存、改善预后的治疗目的。本文以肿瘤恶液质的定义为基础,从三大营养物质的代谢改变出发,总结了目前关于肿瘤恶液质可能的发病机制,进而阐述了肿瘤恶液质的筛查与评定及诊断要点,综述了对应的治疗策略及方法,包括营养干预、运动干预、心理干预及其他药物干预等,并对未来肿瘤恶液质多学科规范化诊疗进行了展望,期望通过多学科诊疗（MDT）的模式,能为肿瘤恶液质患者的早诊早治、延长生存、改善预后提供新的理念,创建新的平台。     

肿瘤联合治疗的时代

多种治疗方法的联合能够提高肿瘤的治疗效果,这是一个肿瘤联合治疗的时代。联合治疗策略包括免疫治疗为基础的联合治疗、微生物治疗实现肿瘤个体化治疗、细胞周期联合治疗、不同靶向药物的联合和化疗联合治疗。多种系统治疗方法的联合也是肿瘤治疗的未来方向。     

肿瘤患者进食能力内科临床技术路线

进食能力下降和胃肠道功能障碍是导致肿瘤患者热量-蛋白质缺乏型营养不良发生的重要原因,正确认识、评估及干预其进食能力及胃肠道功能在肿瘤治疗中不可或缺。全文从肿瘤患者进食能力及胃肠功能障碍的发生机制、诊断评估、治疗、疗效评估、随访等方面进行阐述。结合理论及自身实践经验,为存在进食能力下降和胃肠功能障碍肿瘤患者提供诊断思路、评估及治疗方法,以改善患者的生活质量,提高抗肿瘤治疗耐受性。     

肿瘤整合康复治疗规范化示范病房标准(试行)

肿瘤整合康复治疗旨在帮助肿瘤患者获得最大的身体、社会、心理和职业功能支持,不仅可以减少肿瘤治疗过程中 的各种不良反应带来的负面影响,并且能显著改善肿瘤患者的生存质量。 多学科肿瘤康复团队是肿瘤整合康复的临床实践 基础,团队成员包括临床(中)医师、护士(师)、营养师、运动治疗师/ 康复理疗师、心理咨询/ 心理治疗师/ 精神科医师、个案管 理师等,关键技术涉及营养、运动、心理和症状的筛查、测评、治疗与疗效评价,以及针对症状管理制定明确的康复管理方法。 创建肿瘤整合康复治疗规范化示范病房有助于将多模式整合康复(营养、运动、心理、症状管理)诊疗规范落实到临床实践,提 升康复治疗水平、提高肿瘤患者生活质量、延长患者生存期。     

营养不良肿瘤患者营养支持治疗临床建议路径

摘 要：营养不良的高发人群是恶性肿瘤患者，不仅影响患者机体所有的器官和组织细胞功能，还涉及其心理和社会角色。肿瘤营养疗法是计划、实施并评价营养干预，以治疗肿瘤及其并发症或纠正身体不良状况，改善肿瘤患者临床结局的过程，包括营养筛查/评估、营养干预、疗效评价（含随访）三阶段。营养不良肿瘤患者的营养支持治疗（nutritional supportive care，NSC），应遵循五阶梯治疗原则来补足热量和营养素。     

Clinical practice guidelines on the evidence‐based use of integrative therapies during and after breast cancer treatment

Answer questions and earn CME/CNE Patients with breast cancer commonly use complementary and integrative therapies as supportive care during cancer treatment and to manage treatment‐related side effects. However, evidence supporting the use of such therapies in the oncology setting is limited. This report provides updated clinical practice guidelines from the Society for Integrative Oncology on the use of integrative therapies for specific clinical indications during and after breast cancer treatment, including anxiety/stress, depression/mood disorders, fatigue, quality of life/physical functioning, chemotherapy‐induced nausea and vomiting, lymphedema, chemotherapy‐induced peripheral neuropathy, pain, and sleep disturbance. Clinical practice guidelines are based on a systematic literature review from 1990 through 2015. Music therapy, meditation, stress management, and yoga are recommended for anxiety/stress reduction. Meditation, relaxation, yoga, massage, and music therapy are recommended for depression/mood disorders. Meditation and yoga are recommended to improve quality of life. Acupressure and acupuncture are recommended for reducing chemotherapy‐induced nausea and vomiting. Acetyl‐L‐carnitine is not recommended to prevent chemotherapy‐induced peripheral neuropathy due to a possibility of harm. No strong evidence supports the use of ingested dietary supplements to manage breast cancer treatment‐related side effects. In summary, there is a growing body of evidence supporting the use of integrative therapies, especially mind‐body therapies, as effective supportive care strategies during breast cancer treatment. Many integrative practices, however, remain understudied, with insufficient evidence to be definitively recommended or avoided. CA Cancer J Clin 2017;67:194–232 . © 2017 American Cancer Society .     

The management of kidney cancer

HUGHES A.E., GORNELL S., FISCHER P. & HUGHES S. (2010) European Journal of Cancer Care 19 , 706
The management of kidney cancer This module will help health professionals understand recent new developments in the treatment and management of kidney cancer. Surgical approaches, systemic therapy, management of side effects, issues with self‐administered oral chemotherapy, and developing therapies will be presented.     

Arterial hypertension and cancer

Arterial hypertension and cancer are two of the most important causes of mortality in the world; correlations between these two clinical entities are complex and various. Cancer therapy using old (e.g., mitotic spindle poisons) as well as new (e.g., monoclonal antibody) drugs may cause arterial hypertension through different mechanisms; sometimes the increase of blood pressure levels may be responsible for chemotherapy withdrawal. Among newer cancer therapies, drugs interacting with the VEGF (vascular endothelial growth factors) pathways are the most frequently involved in hypertension development. However, many retrospective studies have suggested a relationship between antihypertensive treatment and risk of cancer, raising vast public concern. The purposes of this brief review have then been to analyse the role of chemotherapy in the pathogenesis of hypertension, to summarize the general rules of arterial hypertension management in this field and finally to evaluate the effects of antihypertensive therapy on cancer disease.     

Complementary and Alternative Cancer Therapies: Past,Present and the Future Scenario

Use of complementary and alternative therapies is widespread among cancer patients. Throughout the world ‍cancer patients try many questionable or unproven treatment methods. The reasons for adopting these therapies are ‍complex and are related to the social and cultural contexts of their geographical locations. In case of severe illness, ‍the desire to leave no stone unturned is a powerful motivator. In developing countries, ignorance, socioeconomics, ‍and inadequate access to mainstream medical facilities are major factors that play an important role for patients ‍opting for alternative therapies that are replacements for mainstream treatment. Whereas in developed countries a ‍significant proportion of cancer patients try complementary therapies as adjuncts to mainstream care for management ‍of symptoms and to improve quality of life. Many alternative therapies, including pharmacological and biological ‍treatments, remain highly controversial but at the same time are very popular. Evidence from randomized trial ‍supports the value of hypnosis for cancer pain and nausea; relaxation therapy and massage for anxiety; and ‍acupuncture for nausea. This article reviews the different popular alternative cancer therapies practiced in India ‍and neighboring south east Asian countries to project the current international scenario on complementary and ‍alternative cancer therapies.‍ ‍     

肿瘤的靶向治疗

靶向治疗是针对肿瘤细胞恶性表型的分子靶点,作用于促进肿瘤生长、存活的特异性细胞受体、信号传导等通道,实现抑制肿瘤细胞生长或促进凋亡的抗肿瘤作用。新的靶向治疗药物rituximab、伊马替尼、赫赛汀和全反式维甲酸已开始用于临床治疗,本文综述这些药物的作用机制、适应证、疗效及安全性。与传统细胞毒化疗不同,肿瘤靶向治疗具有特异性抗肿瘤作用,并且毒性明显减少。肿瘤靶向治疗令人鼓舞的初步成果为其进一步发展奠定了基础,提供了典范,开创了肿瘤化疗的新领域。     

Is there a role for complementary therapy in the management of leukemia?

Patients with leukemia often seek additional treatments not prescribed by their oncologist in an effort to improve their cancer treatment outcome or to manage symptoms. Complementary therapies are used in conjunction with traditional cancer treatments to decrease symptoms and side effects associated with cancer or cancer treatment, and to improve patients’ overall quality of life. Complementary therapies are distinct from so-called ‘alternative’ therapies, which are unproven, ineffective and may postpone or interfere with mainstream cancer treatment. Complementary therapies are pleasant, inexpensive, nonpharmacologic and effective. For patients with leukemia, the complementary therapies that are always appropriate include mind–body interventions, such as self-hypnosis, meditation, guided imagery and breath awareness. Massage and reflexology (foot massage) decrease symptoms with effects lasting at least 2 days following treatment. Acupuncture is very beneficial for symptom management without adverse consequences. Physical fitness with regular exercise and healthy dietary habits can significantly decrease side effects of cancer treatments and may prolong survival. Botanical extracts and vitamin supplements may interfere with active cancer treatments, and should be discussed with the oncologist or pharmacist before use.     

Integrative Oncology Education: An Emerging Competency for Oncology Providers

A growing number of cancer patients use complementary and alternative therapies during and after conventional cancer treatment. Patients are often reluctant to discuss these therapies with their oncologist, and oncologists may have limited knowledge and confidence on how to advise patients on the appropriate use. Integrative oncology is a patient-centered, evidence-informed field that utilizes mind–body practices, lifestyle modifications and/or natural products interwoven with conventional cancer treatment. It prioritizes safety and best available evidence to offer appropriate interventions alongside conventional care. There are few opportunities for oncologists to learn about integrative oncology. In this commentary, we highlight the Integrative Oncology Scholars (IOS) program as a means to increase competency in this growing field. We provide an overview of several integrative oncology modalities that are taught through this program, including lifestyle modifications, physical activity, and mind–body interventions. We conclude that as more evidence is generated in this field, it will be essential that oncology healthcare providers are aware of the prevalent use of these modalities by their patients and cancer centers include Integrative Oncology trained physicians and other healthcare professionals in their team to discuss and recommend evidence-based integrative oncology therapies alongside conventional cancer treatments to their patients.     

American Radium Society Appropriate Use Criteria for the use of liver-directed therapies for nonsurgical management of liver metastases: Systematic review and guidelines

The liver is a common site of cancer metastases. Systemic therapy is widely accepted as the standard treatment for liver metastases (LM), although select patients with liver oligometastases may be candidates for potentially curative liver resection. Recent data support the role of nonsurgical local therapies such as ablation, external beam radiotherapy, embolization, and hepatic artery infusion therapy for management of LM. Additionally, for patients with advanced, symptomatic LM, local therapies may provide palliative benefit. The American Radium Society gastrointestinal expert panel, including members representing radiation oncology, interventional radiology, surgical oncology, and medical oncology, performed a systemic review and developed Appropriate Use Criteria for the use of nonsurgical local therapies for LM. Preferred Reporting Items for Systematic reviews and Meta-Analyses methodology was used. These studies were used to inform the expert panel, which then rated the appropriateness of various treatments in seven representative clinical scenarios through a well-established consensus methodology (modified Delphi). A summary of recommendations is outlined to guide practitioners on the use of nonsurgical local therapies for patients with LM.     

Endocrine therapy and other targeted therapies for metastatic breast cancer

The most important change in the treatment of advanced breast cancer that will emerge over the next 10 years is the shift from adjuvant tamoxifen to adjuvant aromatase inhibitors. This will mean an increasing proportion of tamoxifen-naive aromatase inhibitor-resistant breast cancer. Research of the most appropriate methods of optimizing remaining endocrine sensitivity in these patients is needed. The rapid expansion in the understanding of the molecular basis of breast cancer biology provides potential targets for novel therapies. Despite these pivotal developments, resistance to endocrine therapy remains a key limitation in the management of advanced breast cancer. Until recently, the only option following the development of resistance to an endocrine agent was to change endocrine therapy and, on exhaustion of endocrine sensitivity, to move to cytotoxic chemotherapy. Understanding of at least some of the mechanisms underlying the development of endocrine resistance is now emerging. We now have the tools that may allow us to both overcome resistance and restore sensitivity, or to pre-empt certain types of resistance from developing. These tools include the increasing array of signal transduction inhibitors in combination with standard endocrine agents. Correct clinical management strategy can be guided by preclinical modeling but can only be validated by carefully designed clinical trials. These will, at the very least, need to be conducted with correlative translational research elements that will track changes in tumors as resistance emerges and will allow us to select the most appropriate treatment strategy for individual patients. Amongst the myriad of promising drugs there will undoubtedly be some that fail to meet current hopes, but we can be optimistic that a handful will find a useful place in keeping advanced breast cancer at bay for longer than can be achieved at present. However, the holy grail of a cure is likely, in the medium term, to remain elusively at the end of the rainbow for most of these patients. Several other methods for the management of these patients are in development. These include strategies to overcome endocrine resistance and methods to target deregulated endocrine and growth factor signaling pathways using gene and immunotherapy approaches.     

Integrative oncology in North America

Integrative oncology is an evolving evidence-based specialty that uses complementary therapies in concert with medical treatment to enhance its efficacy, improve symptom control, alleviate patient distress and reduce suffering. In North America the evolution of research into complementary therapies was delayed by the narrow focus of the Flexner Report. A government-funded research agenda and incorporation of complementary therapies into medical school curricula have been driven by early evidence of efficacy and patient demand. Integrative oncology focuses on the role of natural health products (botanicals, vitamins, and minerals), nutrition, acupuncture, meditation and other mind-body approaches, music therapy, touch therapies, fitness therapies, and more. Some natural health products, such as herbs and their constituent phytochemicals, may be biologic response modifiers that could increase cancer control. Current research stretches from the laboratory to health services. Institutions are exploring the effectiveness gap in their clinical services and are determining efficacy of complementary therapies through randomized controlled trials. Eventually, the goal is to establish practice guidelines through determining relative effectiveness and value through cost-utility studies. The aim of integrative oncology should be one medicine, not alternative; it should be patient-focused; it should be evidence-based; and it should provide the best care for cancer cure, prevention, symptom control, and quality of life.