摘要
现在越来越多的研究者意识到健康相关生命质量(Health-related Quality of Life, HRQL)的测量,可以为癌症的治疗决策提供许多重要信息。近年来,癌症患者治疗前、后的生命质量评价已成功的应用于包括前列腺癌、乳腺癌、肺癌和肝癌在内的许多恶性肿瘤的治疗研究中。肿瘤的脊柱转移常见于晚期癌症患者,可以引起病理性骨折、恶性肿瘤高钙血症和脊髓受压。脊髓受压是脊柱肿瘤的严重并发症之一,在脊柱转移性肿瘤患者中的发生率为5～14%。脊髓受压可以引起顽固性疼痛、行走功能丧失以及大小便失禁。由于大多数脊柱转移性肿瘤确诊时已到了晚期,无法治愈,所以在做治疗决策时应重点考虑所选用的治疗方法对患者生命质量的影响。
脊柱肿瘤是临床肿瘤学中相对较少见的一类肿瘤,按其肿瘤的来源可以分为原发脊柱肿瘤和转移性脊柱肿瘤。通过对2000年1月～2007年1月在长征医院脊柱外科行手术治疗脊柱肿瘤的557名患者的病历资料进行回顾性分析,发现原发脊柱肿瘤患者(356名)和转移性脊柱肿瘤患者(201名)的预后有很大差异,前者的术后生存时间远远长于后者,证明手术治疗对原发脊柱肿瘤是有效的。
长期以来对于转移性脊柱肿瘤的手术治疗一直是临床上争论的焦点,国内外文献中关于脊柱转移性肿瘤患者健康相关生命质量方面的信息很有限,之前没有关于脊柱转移性肿瘤患者手术后长期生命质量研究的报道。因此,本研究设计并实施了一项前瞻性、纵向、非随机对照研究,目的在于辨别、比较接受脊柱肿瘤手术的患者和未接受脊柱肿瘤手术的患者生命质量随时间变化的情况,为临床治疗决策提供科学依据。
将2007年7月1日到2009年3月31日在第二军医大学上海长征医院确诊为转移性脊柱肿瘤且符合本研究条件的312名患者按其是/否接受脊柱肿瘤手术分为手术组(147名)和非手术组(165名)。所有入选患者分别在确诊时,确诊后(手术后)第1、3、6、9个月,应用FACT-G (Functional Assessment of Cancer Therapy-General)癌症患者生命质量评价量表进行了5次生命质量测评。
在研究进行过程中,对所有2009年1月1后入组的患者在生命质量测量的基础上增加了焦虑、抑郁症状和疼痛程度的测量。共有216名患者符合条件,其中手术组(101名),非手术组(115名)。焦虑状态的测评选用Zung氏焦虑自评量表,抑郁状态的测评选用Zung氏抑郁自评量表,疼痛程度的测评选用数字疼痛分级法。
研究结果显示手术治疗能够显著提高脊柱转移性肿瘤患者的生命质量,有效缓解患者的焦虑、抑郁症状,明显控制疼痛状况,但不能延长脊柱转移性肿瘤患者的生存时间。
设计并实施这一前瞻性、纵向、对照研究的目的在于揭示脊柱手术对脊柱转移性肿瘤患者生命质量的影响,辨别、比较手术/非手术后患者生命质量,焦虑、抑郁症状和疼痛程度随时间变化的规律,为临床决策提供科学依据。从总体上说转移癌不可能治愈,因此治疗的目的大多在于延长存活时间及减轻症状。一些研究者主张把放疗作为脊柱转移性肿瘤的标准疗法,手术仅仅作为放疗失败后的二线疗法,或仅仅用于疼痛的控制。近年来,随着外科技术的发展,手术治疗越来越多的应用于脊柱转移性肿瘤的治疗当中。脊柱手术能否提高脊柱转移性肿瘤患者的生命质量?虽然健康相关生命质量的重要性已得到广泛认同,但关于手术对脊柱转移性肿瘤患者长期生命质量影响方面的资料几乎没有。具了解,本研究是最早关注这个问题的。本研究的结果提示手术对脊柱转移性肿瘤的治疗很有效。
There has been growing recognition that patient-reported outcome measures, in particular, measures of health-related quality of life (HRQOL), can convey important information for the choosing and decision-making of treatment of cancer. In recent years, successful quality of life (QOL) evaluation has been performed on patients with prostate, breast, lung, and hepatic cancer after treatment. Spine metastases are common among patients with advanced-stage cancer, which can lead to pathologic fracture, hypercalcemia of malignancy, and spinal cord compression. Spinal cord compression is a severe complication of cancer, occurring in 5-14% of the metastatic cancer patients, which can cause intractable pain, loss of mobility, and incontinence. Since most spinal metastases are detected at later stages, by when it is in general incurable, the impact of treatment on QOL should therefore be an important consideration in our treatment decisions.
Spinal tumors, including primary spine tumor and metastatic spinal tumor. We compiled 557 patients who underwent spinal surgery in Changzheng Hospital from January,2000 to January 2007. Through retrospective analysis, we found surgical treatment of primary spinal tumors is effective.
The surgical treatment of metastatic spinal tumors has been the focus of debate in clinical for quite some time. However, HRQOL data for spinal metastases is limited. To our knowledge, there has been no previous report on the QOL outcome after surgery for spinal metastases. The purpose of this prospective, longitudinal study was to identify and compare the QOL of patients over a certain period of time after spinal surgery.
From July 1,2007 to March 31,2009, we identified 312 patients who were eligible for the observational study from Changzheng Hospital, the Second Military Medical University in Shanghai, China. All eligible patients were separated into two groups depending on whether they would undergo the surgery or not (surgery group n=147, non-surgery group n=165). When diagnosed, all eligible patients completed a baseline QOL assessment using the Functional Assessment of Cancer Therapy-General (FACT-G) Questionnaire. The surgery group patients received surgical treatment within 3 days after diagnosis. Patients were assessed again at 4 time points:1 month,3 months,6 months and 9 months during the postoperative period. The non-surgery group QOL assessments were performed at 1 month,3 months,6 months and 9 months following diagnosis.
During the course of the study, we added anxiety, depression and pain assessment to the QOL assessment to those patients who enter after January 1,2009.216 patients were eligible, including surgery group 101 and non-surgery group 115. Use Zung's Self-Rating Anxiety Scale (SAS) for anxiety assessment, Zung's Self-Rating Depression Scale (SDS) for depression assessment, and Numeric Rating Scale (NRS) for pain assessment.
The results of this study suggest that surgical treatment can improve the QOL of patients with spinal metastases greatly, reduce anxiety and depression, and control pain, but can not prolong the survival time.
In order to reveal the impacts of spinal surgery on the QOL, anxiety, depression, and pain of patients with spinal metastases, this prospective, longitudinal study has been designed and implemented, using a non-surgery group as the control group. Metastatic disease is generally incurable, so treatments are usually aimed at the prolongation of survival and palliation of symptoms. QOL assessment in studies helps evaluate the benefits or risks of any therapy. Some researchers claim the standard treatment for spinal metastases is radiotherapy; and surgery is only applied as a second-line treatment when radiotherapy has failed, or sometimes merely for pain control. However, in recent years, with the development of surgical techniques, surgeries have been increasingly applied to treat spinal metastases. Can spinal surgery indeed improve the QOL of patients with spinal metastases? Although the importance of health-related quality of life outcome has been widely recognized, information and study on the impact of surgery on QOL of patients with spinal metastases is far from sufficient. To our knowledge, this study is actually the first attempt to address the issue. This finding supports the use of surgery as an effective treatment for spinal metastases.
引文
[1]http://www.shczyy.com/depart.aspx?id=35
[2]肖建如主编.脊柱肿瘤外科学.上海：上海科学技术出版社,2004：3-5.
[3]肖建如主编.脊柱肿瘤外科学.上海：上海科学技术出版社,2004：1-3.
[4]陈华江,肖建如,贾连顺.原发性脊柱肿瘤外科治疗现状与进展.国外医学骨科学分册,2003,24(3)：151-154.
[5]Fourney DR, Rhines LD, Hentschel SJ, et al. En bloc resection of primary sacral tumors:classification of surgical approaches and outcome. Neurosurg Spine,2005, 3(2):111-122.
[6]Schmidt MH, Fourney DR, Gokaslan ZL. Metastatic spine disease. Neurosurg Clin N Am,2004,15(4):15-16.
[7]Villavicencio AT, Oskouian RJ, Roberson C, et al. Thoracolumbar vertebral reconstruction after surgery for metastatic spinal tumors:long-term outcomes. Neurosurg Focus,2005,19(3):E8.
[8]Aebi M. Spinal metastasis in the elderly. Eur Spine,2003,12(S2):202-213.
[9]徐万鹏,李佛保主编.骨与软组织肿瘤学.北京：人民卫生出版社,2008：4.
[10]胡有谷,党耕町,唐天驷主译.脊柱外科学(第2版).北京：人民卫生出版社,2005：1897.
[11]孙颖浩.我国前列腺癌的研究现状.中华泌尿外科杂志,2004,25(2)：77-80.
[12]陈杰,徐丹枫,高轶等.前列腺癌3种常用治疗方法的生存和预后分析及影响因素.中国癌症杂志,2009,29(7)：512-516.
[13]靳锁翠.乳腺癌根治术后并发症及人性化护理.护理研究,2009,23(5)：1371-1372.
[14]第五届欧洲肺癌会议摘要.继续医学教育,2005,29(2)：56-57.
[15]舒立群.肺癌359例分析.临床肺科杂志,2008,13(9)：1172.
[16]金萍,李萍,潘景艳等.腹腔镜下肾癌根治性切除术患者的护理.中国实用护理杂志,2007,23(7)：33-34.
[17]http://www.who.int/entity/healthinfo/statistics/bodgbddeathdalyestimates.xls
[18]Virginia S, Betty F, Gloria J, et al. Symptom concerns and quality of life in hepatobiliary cancers. Oncol Nurs Forum,2008,35(3):45-52.
[19]中国抗癌协会肝癌专业委员会,中国抗癌协会临床肿瘤学协作专业委员会,中华医学会肝病学分会肝癌学组.原发性肝癌规范化诊治的专家共识.肿瘤,2009,29(4)：295-304.
[20]肖建如主编.脊柱肿瘤外科学.上海：上海科学技术出版社,2004：7-10.
[21]胡有谷,党耕町,唐天驷主译.脊柱外科学(第2版).北京：人民卫生出版社,2005：1904.
[22]徐万鹏,李佛保主编.骨与软组织肿瘤学.北京：人民卫生出版社,2008：244-245.
[23]肖建如,魏海峰,陈华江,滕红林,杨兴海,王长峰,袁文,陈雄生,贾连顺.儿童及青少年脊柱肿瘤.中华骨科杂志,2004,24(7)：395-398.
[24]Johnson JR, R Temple. Food and Drug Administration requirements for approval of new anticaner drugs. Cancer Treat Rep,1985,69(10):1155-1159.
[25]王吉耀.循证医学与临床实践.北京：科学出版社,2006：211-227.
[26]晓煜,黄燕芳.医学模式与哲学.医学与社会杂志,2000,13(4)：13-15.
[27]Sebastian E, Stromberg AJ, Ames S, Ellis S, McMasters KM, Martin RCG Assessment of symptom experience in patients undergoing hepatic resection or ablation. Cancer,2006,107(11):2715-2722.
[28]Steel JL, Eton DT, Cella D, Olek MC, Carr BI. Clinically meaningful changes in health-related quality of life in patients diagnosed with hepatobiliary carcinoma. Ann Oncol,2006,17(2):304-312.
[29]Addeo R, Caraglia M, Faiolal V, et al. Concomitant treatment of brain metastasis with whole brain radiotherapy [WBRT] and Temozolomide [TMZ] is active and improves quality of life. BMC Cancer 2007,7:18 doi:10.1186/1471-2407-7-18.
[30]李忠民,孙振球.循证医学中的科学人文精神.中国循证医学杂志,2005,5(10)：804-806.
[31]Bilsky MH, Lis E, Raizer J et al. The diagnosis and treatment of metastatic spinal tumor. Oncologist,1999,4(6):459-469.
[32]Gasbarrini A, Cappuccio M, Mirabile L, et al. Spinal metastases:treatment evaluation algorithm. Eur Rev Med Pharmacol Sci,2004,8:265-274.
[33]Tanaka M, Nakahara S, Ito Y, et al. Surgical treatment of metastatic vertebral tumors. Acta Med. Okayama,2009,63(6):145-150.
[34]Donthineni R, Ofluoglu O. Spine Oncology:Daedalus, Theseus, and the Minotaur. Orthop Clin N Am,2009,40:169-171.
[35]胡有谷,党耕町,唐天驷主译.脊柱外科学(第2版).北京：人民卫生出版社,2005：1909-1942.
[36]Lipscomb J, Gotay CC, Snyder CF. Patient-reported outcomes in cancer:a review of recent research and policy initiatives. CA Cancer J Clin,2007,57(5):278-300.
[37]万崇华,罗家洪,杨铮,孟琼.癌症患者生命质量测定与应用.北京：科学出版社,2007：62-73.
[38]Kemmler G, Holzner B, Kopp M, et al. Comparison of two quality-of-life instruments for cancer patients:the Functional Assessment of Cancer Therapy-General and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30. J Clin Oncol,1999,17(9):2932-2940.
[39]Bonomi AE, Cella DF, Hahn EA, et al. Multilingual translation of the Functional Assessment of Cancer Therapy (FACT) quality of life measurement system. Qual Life Res, 1996,5(3):309-320.
[40]Dapueto JJ, Servente L, Francolino C, Hahn EA. Determinants of quality of life in patients with cancer:a south American study. Cancer,2005,103(5):1072-1081.
[41]Cheung YB, Goh C, Wee J, Khoo KS, Thumboo J. Measurement properties of the Chinese language version of the Functional Assessment of Cancer Therapy-General in a Singaporean population. Ann Acad Med Singapore,2009,38(3):225-229.
[42]Heffernan N, Cella D, Webster K, et al. Measuring health-related quality of life in patients with hepatobiliary cancers:the Functional Assessment of Cancer Therapy-Hepatobiliary Questionnaire. J Clin Oncol,2002,20(9):2229-2239.
[43]Frankel HL. Ascending cord lesion in the early stages following spinal injury. Paraplegia,1969,7:111-118.
[44]贾连顺主编.现代脊柱外科学.北京：人民军医出版社,2007：488-489.
[45]Onimus M, Papin P, Gangloff S. Results of surgical treatment of spinal thoracic and lumbar metastases. Eur Spine,1996,5:407-411.
[46]刘书盈.我国肺癌治疗中的若干问题.中华临床医师杂志(电子版),2009,3(5)：10-12.
[47]郁宝铭.结直肠癌治疗的新概念——综合治疗的发展和展望.外科理论与实践,2003,8(3)：261-264.
[48]陈强,林万隆.胃癌治疗的监测和随访.策略世界肿瘤杂志,2005,4(1)：1-2.
[49]张力,鼻咽癌治疗的新进展.临床肿瘤学杂志,2008,13(3)：193-196.
[50]李汉忠,严维刚.前列腺癌治疗新进展.医学研究杂志,2007,36(9)：6-7.
[51]欧盟批准诺华公司依维莫司用于晚期肾癌治疗.世界临床药物,2009,30(9).
[52]余永利,不摄取131I的甲状腺癌治疗.国外医学·放射医学核医学分册,2005,29(2)：57-63.
[53]王明,窦拉加.乳腺癌治疗的发展趋势.中国临床医药研究杂志,2008,199：45-47.
[54]张嘉庆,王殊.关注中国乳腺癌治疗的外科问题.中华普外科手术学杂志(电子版),2008,2(2)：3-4.
[55]程志祥,王科明.生存质量评价在乳腺癌治疗中的应用.中国肿瘤临床,2009,36(7)：417-420.
[56]钟润波,韩宝惠.小细胞肺癌治疗回顾与展望.中国癌症杂志,2008,18(2)：147-151.
[57]孙振球,徐勇勇主编.医学统计学.北京：人民卫生出版社,2004：494.
[58]万崇华,孟琼,汤学良,张灿珍,罗家洪,张晓磐.癌症患者生命质量测定量表FACT-G中文评介.实用肿瘤杂志,2006,21(1)：77-80.
[59]杨锐,陈钒,戚宜晶,张艳玲,郭美珠,王金红.宁养院患者的临终关怀和药物治疗.中国现代药物应用,2008,2(1)：48-50.
[60]黄少卿,蔡泽玲,陈碧素,李文苑,卢锡芝.国内宁养家居护理现况.实用医技杂志,2006,13(12)：2143-2144.
[61]Ibrahim A, Crockard A, Antonietti P, et al. Does spinal surgery improve the quality of life for those with extradural (spinal) osseous metastases? An international multicenter prospective observational study of 223 patients. Neurosurg Spine,2008,8(3):271-278.
[62]周乃康.肺癌治疗模式探讨与见解.中华临床医师杂志(电子版),2009,3(5)：1-3.
[63]Tsuya A, Fukuoka M. Bone metastases in lung cancer. Clin Calcium,2008, 18(4):455-459.
[64]McArthur HL, Hudis CA. Has first-line therapy had an impact on general outcome in metastatic breast cancer? Future Oncol,2007,3(4):411-418.
[65]Kaya E, Feuer D. Prostate cancer:palliative care and pain relief. Prostate Cancer Prostatic Dis,2004,7(4):311-315.
[66]Patchell RA, Tibbs PA, Regine WF, et al. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer:a randomised trial. Lancet,2005,366:643-648.
[67]Patrick DL, Chiang YP. Measurement of health outcomes in treatment effectiveness evaluations:conceptual and methodological challenges. Med Care,2000,38(9):14-25.
[68]孙振球,徐勇勇主编.医学统计学.北京：人民卫生出版社,2004：397-413.
[69]冯显威.论循证医学的兴起及其思维模式与方法.医学与哲学杂志,2003,24(4)：18-20.
[70]Sackett DL, Straus SE, Richhardson WS et al. Evidence-based medicine. How to practice and teach EBM. Edinbugh:Churchill Livingstone,2000:1-12.
[71]王家良.临床治疗性研究的设计与评价.中华医学杂志,1999,79(2)：94-96.
[72]Findlay GF. Adverse effects of the management of malignant spinal cord compression. Neurol Neurosurg Psychiatry,1984,47(8):761-768.
[73]Kocialkowski A, Webb JK. Metastatic spinal tumors:survival after surgery. Eur Spine J,1992, 1(1):43-48.
[74]Loblaw DA, Perry J, Chambers A, Laperriere NJ. Systematic review of the diagnosis and management of malignant extradural spinal cord compression:the cancer care Ontario practice guidelines initiative's neuro-oncology disease site group. J Clin Oncol,2005, 23(9):2028-2037.
[75]Choi D, Crockard A, Bunger C, et al. Review of metastatic spine tumour classification and indications for surgery:the consensus statement of the Global Spine Tumour Study Group. Eur Spine J.2010,19(2):215-222.
[76]陶炯,叶明志,易欢琼,温盛霖,王相兰.癌症患者的心身状况及心理干预.中山大学学报(医学科学版),2005,26(5)：582-586.
[77]王中栋,张沂平,娄广媛.抗焦虑治疗改善癌症患者焦虑抑郁62例分析.中国肿瘤,2007,16(11)：961-962.
[78]Parkin DM, Bray F, Ferlay J, Pisani P. Global cancer statistics,2002. CA Cancer J Clin,2005,55(2):74-108.
[79]Lindsay WR, Michie AM. Adaptation of the Zung self-rating anxiety scale for people with a mental handicap. J Ment Defic Res,1988,32(6):485-490.
[80]Merz WA, Ballmer U. Demographic factors influencing psychiatric rating scales (Zung SDS and SAS). Pharmacopsychiatry,1984,17(2):50-56.
[81]Yeh YC, Yen CF, Lai CS, Huang CH, Liu KM, Huang IT. Correlations between academic achievement and anxiety and depression in medical students experiencing integrated curriculum reform. Kaohsiung J Med Sci,2007,23(8):379-386.
[82]方燕南,王雪晶,李洵桦,马明明,黄如训,曾进胜.西比灵与阿米替林防治偏头痛疗效研究.中国疼痛医学杂志,2005,11(5)：267-269.
[83]Olatunji BO, Deacon BJ, Abramowitz JS, Tolin DF. Dimensionality of somatic complaints:factor structure and psychometric properties of the Self-Rating Anxiety Scale. J Anxiety Disord,2006,20(5):543-561.
[84]Dugan W, McDonald MV, Passik SD, Rosenfeld BD, Theobald D, Edgerton S. Use of the Zung Self-Rating Depression Scale in cancer patients:feasibility as a screening tool. J Psychooncolgy,1998,7(6):483-493.
[85]Passik SD, Kirsh KL, Donaghy KB, Theobald DE, Lundberg JC, Holtsclaw E, Dugan W. An attempt to employ the Zung Self-Rating Depression Scale as a "lab test" to trigger follow-up in ambulatory oncology clinics:criterion validity and detection. J Pain Symptom Manage,2001,21(4):273-281.
[86]Kitzlerova E, Anders M, Kautzner J, Dohnalova A. Evaluation of psychopathology in patients with paroxysmal supraventricular tachycardia. Exp Clin Cardiol,2007, 12(1):42-45.
[87]Aragones E, Pinol JL, Labad A. The overdiagnosis of depression in non-depressed patients in primary care. Fam Pract,2006,23(3):363-368.
[88]Philipp M, Kohnen R, Hiller KO. Hypericum extract versus imipramine or placebo in patients with moderate depression:randomised multicentre study of treatment for eight weeks. BMJ,1999,319(7224):1534-1538.
[89]Matsushita T, Matsushima E, Maruyama M. Anxiety and depression of patients with digestive cancer. Psychiatry Clin Neurosci,2005,59(5):576-583.
[90]王汝展,刘兰芬,葛红敏,韩建波.Zung氏抑郁自评量表(SDS)作为外科住院患者抑郁障碍常规筛查工具的可行性研究.精神医学杂志,2009,22(4)：251-253.
[91]柴萌,唐宏宇,韩素霞,曹莉,鲍震文,康凌.北京市新入监罪犯人格特点及心理卫生状况.中国心理卫生杂志,2004,18(5)：333-335.
[92]洪瑞乔,王逸茹,林赛娥,李德锐.数字疼痛分级法在癌症疼痛质量中的应用.实用护理杂志,2003,19(7)：48-49.
[93]Lorenz KA, Sherbourne CD, Shugarman LR, et al. How reliable is pain as the fifth vital sign? J Am Board Fam Med,2009,22(3):291-298.
[94]Herr K, Titler MG, Schilling ML, et al. Evidence-based assessment of acute pain in older adults:current nursing practices and perceived barriers. Clin J Pain,2004, 20(5):331-340.
[95]Manchikanti L, Cash KA, McManus CD, Pampati V, Abdi S. Preliminary results of a randomized, equivalence trial of fluoroscopic caudal epidural injections in managing chronic low back pain:Part 4--Spinal stenosis. Pain Physician,2008,11 (6):833-848.
[96]郭向丽,赵继军.疼痛评估的研究进展.护理学报,2008,15(12)：8-10.
[97]Dunner DL, Goldstein DJ, Mallinckrodt C, Lu Y, Detke MJ. Duloxetine in treatment of anxiety symptoms associated with depression. Depress Anxiety,2003,18(2):53-61.
[98]Bunevicius A, Peceliuniene J, Mickuviene N, Valius L, Bunevicius R. Screening for depression and anxiety disorders in primary care patients. Depress Anxiety,2007, 24(7):455-460.
[99]郭莉,刘丽华,刘志敏.晚期癌症患者生活质量的影响因素及护理对策.护理实践与研究,2009,6(1)：98-101.
[100]Porter LS, Keefe FJ, Garst J, McBride CM, Baucom D. Self-efficacy for managing pain, symptoms, and function in patients with lung cancer and their informal caregivers: associations with symptoms and distress. Pain,2008,137(2):306-315.
[101]石其昌,章健民,徐方忠.浙江省15岁及以上人群精神疾病流行病学调查.中华预防医学杂志,2005,39(4)：229-236.
[102]李兰英,李莉,李志英.癌症患者术前焦虑、抑郁情绪影响因素的调查研究.中国现代医生,2008,46(12)：113-116.
[103]Carney CP, Jones L, Woolson RF, Noyes R Jr, Doebbeling BN. Relationship between depression and pancreatic cancer in the general population. Psychosom Med,2003, 65(5):884-888.
[104]麦桃香,吴娜影,谢春梅,唐小尤.癌症患者疼痛和社会心理状况的调查研究.实用医学杂志,2008,24(1)：133-135.
[105]田晓山,周宏灏,胡春宏,刘珈.姑息治疗与临终关怀中的人文精神—有感于晚期癌症患者的救治现状.中国医学伦理学,2009,22(2)：50-55.
[106]Potter J, Hami F, Bryan T, Quigley C. Symptoms in 400 patients referred to palliative care services:prevalence and patterns. Palliat Med,2003,17(4):310-314.
[107]张培新,赵彦南,王春雨.60例癌症患者的心理状态调查.临床肿瘤学杂志,2008,13(10)：917-919.
[108]Silver J, Mayer RS. Barriers to pain management in the rehabilitation of the surgical oncology patient. J Surg Oncol,2007,95(5):427-435.
[109]姚全军,卢武胜,肝癌的血管介入治疗.华西医学,2008,23(3)：668-669.
[110]Andreassen CN, Alsner J. Genetic variants and normal tissue toxicity after radiotherapy:a systematic review. Radiother Oncol,2009,92(3):299-309.
[111]刘华,王蔚,郑垂志,邢雪花.癌症三阶梯止痛563例分析.中国肿瘤临床,2004,31(23)：1346-1348.
[112]Dalton JA, Youngblood R. Clinical application of the World Health Organization analgesic ladder. J Intraven Nurs,2000,23(2):118-124.
[113]Slavin KV, Tesoro EP, Mucksavage JJ. The treatment of cancer pain. Drugs Today (Barc),2004,40(3):235-245.
[114]Langer C, Hirsh V. Skeletal morbidity in lung cancer patients with bone metastases: demonstrating the need for early diagnosis and treatment with bisphosphonates. Lung Cancer,2010,67(1):4-11.
[115]Bryson JE, Gourlay ML. Bisphosphonate use in acute and chronic spinal cord injury: a systematic review. J Spinal Cord Med,2009,32(3):215-225.
[116]Wowra B, Muacevic A, Zausinger S, Tonn JC. Radiosurgery for spinal malignant tumors. Dtsch Arztebl Int,2009,106(7):106-112.
[117]Rao S, Badani K, Schildhauer T, Borges M. Metastatic malignancy of the cervical spine. A nonoperative history. Spine,1992,17(10 Suppl):S407-412.
[118]Mendel E, Bourekas E, Gerszten P, Golan JD. Percutaneous techniques in the treatment of spine tumors:what are the diagnostic and therapeutic indications and outcomes? Spine,2009,34(22 Suppl):S93-100.
[119]Wilkinson AN, Viola R, Brundage MD. Managing skeletal related events resulting from bone metastases. BMJ.2008 Nov 3;337:a2041. doi:10.1136/bmj.a2041.
[120]Gerszten PC, Mendel E, Yamada Y. Radiotherapy and radiosurgery for metastatic spine disease:what are the options, indications, and outcomes? Spine,2009,34(22 Suppl):S78-92.
[121]胡云州.脊柱肿瘤的治疗.中华骨科杂志,2000,20：58-60.(12月增刊)
[122]万崇华,罗家洪,杨铮,孟琼.癌症患者生命质量测定与应用.北京：科学出版社,2007：8.
[123]孙振球,徐勇勇主编.医学统计学.北京：人民卫生出版社,2004：400.
[124]McHomey CA.Measuring and monitoring general health status in elderly persons: practical and methodological issues in using the SF-36 Health Survey. Gerontologist,1996, 36(5):571-583.
[125]Stewart M. The Medical Outcomes Study 36-item short-form health survey (SF-36). Aust J Physiother,2007,53(3):208.
[126]Schipper H, Clinch J, McMurray A, Levitt M. Measuring the quality of life of cancer patients:the Functional Living Index-Cancer:development and validation. J Clin Oncol,1984,2(5)：472-483.
[127]万崇华,方积乾,张灿珍,汤学良,罗艳敏,林颖.FLIC量表用于肝癌患者生命质量测定的对比研究.中国行为医学科学,2000,9(5)：321-322.
[128]吴万垠,龙顺钦,张海波,柴小姝,邓宏,薛晓光,王斌,罗海英,刘伟胜.参附注射液改善GP方案治疗非小细胞肺癌患者的生活质量.中国中西医结合杂志2006,12(1)：50-54.
[129]吴万垠,周宇妹,邓宏,龙顺钦,郑剑霄,柴小姝,薛晓光,河文峰,蔡姣芝,张海波,孙良生.亚砷酸胸腔内灌注联合体外高频热疗对癌性胸水患者生活质量的影响.上海中医药杂志,2008,42(10)：24-26.
[130]刘译鸿,徐凯,陈达灿.仙龙定痛饮治疗骨转移癌痛的临床观察.世界中医药,2007,2(5)：274-275.
[131]杨铮,卢玉波,李云峰,万崇华,罗家洪,孟琼,张晓罄.大肠癌患者生命质量测定量表FACT-C (V4.0)中文版应用评价.中国组织工程研究与临床康复,2007,11(43)：8753-8756.
[132]罗家洪,汤学良,李晓江,杨铮,徐衍,高良敏.头颈癌生命质量测定量表FACT-HN的信度与效度多因素分析.中国医院统计,2007,14(2)：105-107.
[133]万崇华,张冬梅,汤学良,张文莉,李文辉,任宏轩,和瑞生,王雯.乳腺癌患者生命质量测定量表(FACT-B)中文版的修订.中国心理卫生杂志,2003,17(5)：298-300.
[134]邹建军,郑莹,钱建新,顾小强,王杰军.上海市部分社区癌症患者生活质量影响因素的研究.中华流行病学杂志,2005,26(10)：761-766.
[135]陈鹏,王海江,朱琳,凤小花,贾蕊.FACT-G问卷评估影响胃肠道恶性肿瘤患者生命质量的相关因素.苏州大学学报,2007,27(5)：783-792.
[136]柯爱武,汪敏,周海滨,彭绩,聂绍发.早期乳腺癌患者生命质量及其影响因素分析.中国热带医学,2006,6(4)：726-728.
[137]汪敏,周海滨,彭绩,熊田甜,曲江文,聂绍发.武汉市早期乳腺癌患者生命质量及影响因素分析.公共卫生与预防医学,2006,17(3)：27-30.
[138]薛曹怡,周雷,黄萍萍,顾海雁,倪红伟,钱序.上海市徐汇区6社区乳腺癌患者生命质量现况及影响因素分析.上海精神医学,2008,20(6)：352-356.
[139]王小钦,林果为,季建林,王倩.急性白血病长期生存患者生命质量调查.中国慢性病预防与控制,2001,9(5)：213-215.
[140]王小钦,林果为.上海市急性白血病长期生存患者生命质量调查.中华流行病学杂志,2003,24(11)：1049-1051.
[141]孟琼,万崇华,罗家洪.癌症患者生活质量测定量表EORTC QLQ-C30的应用概况.国外医学-社会医学分册,2004,21(4)：147-150.
[142]孟琼,万崇华,罗家洪.癌症患者生命质量测定量表EORTC QLQ-C30的应用.中国行为医学科学,2005,14(3)：273-274.
[143]万崇华,陈明清,张灿珍,汤学良,孟琼,张晓磬.癌症患者生命质量测定量表EORTC QLQ-C30中文版评介.实用肿瘤杂志,2005,20(4)：353-355.
[144]王建平,陈仲庚,林文娟,崔俊南.中国癌症病人生活质量的测定—EORTCQLQ-C30在中国的试用.心理学报,2000,33(4)：438-442.
[145]姜宝法,刘春晓,崔永春,徐涛,徐敏,王家林,杜君.EORTC QLQ-C30的信度、效度研究.中国临床心理学杂志,2005,13(1)：31-33.
[146]姜宝法,徐涛,刘春晓,徐敏,崔永春,王家林,杜君.胃癌患者生活质量问卷QLQ-STO22中文版的制定.中国心理卫生杂志,2005,19(5)：310-312.
[147]闫春梅,王慧琳,范秀珍,王建平.QLQ-BR23在我国康复期乳腺癌患者中使用的信度和效度分析.护理学杂志(外科版),2007,22(22)：53-55.
[148]程晓麟,周德明,吕丽萍.EORTC QLQ问卷表评估影响肺癌患者生命质量的相关因素.中国肺癌杂志,2004,7(3)：230-235.
[149]陈鹏,王海江,朱琳,贾蕊,简红云.胃肠道癌患者生命质量影响因素初探.癌症,2007,26(10)：1116-1121.
[150]刘巍,宋丽楠,关丽云,陈勇,王士杰,郝希山.胸段食管癌及食管胃交界部癌根治术后患者生存质量影响因素的研究.中国肿瘤临床,2009,36(15)：875-878.
[151]吴剑,翁欣然,林权冰,戴慧,卢晓红,沈洁.鼻咽癌放疗后生存质量的评价分析.实用医学杂志,2009,25(8)：1241-1243.
