践行患者受益的基本原则——从累及泌尿生殖系统复杂子宫内膜异位症临床处置谈起

“患者受益”作为临床处置决策的基本原则在日常的医疗工作中发挥着积极的作用。同样也在常见类型子宫内膜异位症（EM）诊疗过程中得到很好地贯彻执行。然而,对于少见的累及泌尿系的EM,由于缺乏可靠的临床循证医学证据用以指导患者具体的临床处理,把握患者利益最大化原则就显得尤为重要。怎样掌握累及泌尿生殖系子宫内膜异位症患者临床处置决策中的关键要素,尽可能为患者保留生殖能力与泌尿系统的完整性,以提高日后的生活质量。除需要详细了解患者病史特别是手术史、盆腔影像学检查、肾脏功能评估结果外,选择个性化的干预手段并对预后进行综合评估,制定最为适合的治疗方案是至关重要的。本文结合临床典型病例就此问题做一剖析。     

早期子宫颈癌根治性子宫颈切除术的临床应用

近年来子宫颈癌发病率呈现上升及年轻化趋势,年轻宫颈癌患者需要保留生育功能.随着研术式和腹腔镜的发展,子宫颈根治性切除术作为治疗早期宫颈癌的一种新的治疗方法,严格掌握其手术实施的适应证,结合医学伦理学和循证医学的原则,既达到了根治性的目的,又充分考虑到生育功能的保留.因此子宫颈根治性切除术是一种可行、有效、合理的手术方式.     

早期宫颈癌术式选择的比较研究

根治性子宫切除术与保留生育功能的根治性宫颈切除术均可用于早期宫颈癌患者的手术治疗。根据生物-心理-社会医学模式的要求,本文采用比较治疗学的方法,对这两种手术方式,从适应证、手术方式、并发症、疗效等方面进行比较,为宫颈癌临床科学决策提供借鉴。     

早期子宫颈癌根治性子宫颈切除术的临床应用

近年来子宫颈癌发病率呈现上升及年轻化趋势,年轻宫颈癌患者需要保留生育功能。随着新术式和腹腔镜的发展,子宫颈根治性切除术作为治疗早期宫颈癌的一种新的治疗方法,严格掌握其手术实施的适应证,结合医学伦理学和循证医学的原则,既达到了根治性的目的,又充分考虑到生育功能的保留。因此子宫颈根治性切除术是一种可行、有效、合理的手术方式。     

早期宫颈癌术式选择的比较研究

根治性子宫切除术与保留生育功能的根治性宫颈切除术均可用于早期宫颈癌患者的手术治疗.根据生物-心理-社会医学模式的要求,本文采用比较治疗学的方法,对这两种手术方式,从适应证、手术方式、并发症、疗效等方面进行比较,为宫颈癌临床科学决策提供借鉴.     

妇科恶性肿瘤患者保留女性正常生理功能的思考

妇科医生需重视对妇科恶性肿瘤患者进行保留女性正常生理功能的治疗。对少女、育龄期妇女及早期患者治疗恶性肿瘤的同时,应尽量保留其正常的生理功能。需对患者进行全面评估,严格掌握实施保留生育功能手术的适应证;为预防放化疗对卵巢功能的损害,可以采取卵巢移位、卵巢组织冷冻移植,也可通过辅助生殖技术进行未成熟卵泡培养、卵子冷冻、卵母细胞冷冻及胚胎冷冻等。     

循证医学与卵巢癌的治疗

循证医学(EBM)是在临床实践中通过科学的方法获得最充分的证据,并对病人做出最佳诊治决策的一门科学。目前卵巢癌的治疗还存在很多不规范的问题,利用循证医学观点来指导卵巢癌治疗方案的选择,对保留患者的生育功能、生理功能、提高生活质量有着重要的指导意义。     

子宫内膜癌患者治疗方式的选择

子宫内膜癌是女性生殖道常见的恶性肿瘤之一,其主要的治疗手段是手术,传统的治疗术式将双侧卵巢一并切除。随着医学模式的转变,现代医学提出了新的观点一保留卵巢功能,但是卵巢保留有其风险性和安全性,这就要求选择保留卵巢时要慎重。     

子宫内膜癌患者治疗方式的选择

子宫内膜癌是女性生殖道常见的恶性肿瘤之一,其主要的治疗手段是手术,传统的治疗术式将双侧卵巢一并切除;随着医学模式的转变,现代医学提出了新的观点一保留卵巢功能,但是卵巢保留有其风险性和安全性,这就要求选择保留卵巢时要慎重.     

循证医学与卵巢癌的治疗

循证医学(EBM)是在临床实践中通过科学的方法获得最充分的证据,并对病人做出最佳诊治决策的一门科学.目前卵巢癌的治疗还存在很多不规范的问题,利用循证医学观点来指导卵巢癌治疗方案的选择,对保留患者的生育功能、生理功能、提高生活质量有着重要的指导意义.     

卵巢上皮性癌治疗后血清CA125再升高的治疗选择：积极化疗，抑或是观察等待？

卵巢上皮性癌是恶性程度、病死率极高的卵巢肿瘤,几乎所有的经规范治疗后的卵巢上皮性癌都存在复发风险,复发较大程度上意味着不良预后,甚至死亡。与卵巢癌相关的肿瘤抗原（CA125）是观察、诊断卵巢上皮性癌术后复发的敏感指标,对复发早期无影像学证据,仅单纯 CA125升高的卵巢上皮性癌患者是积极化疗,抑或是观察等待？一直是妇科肿瘤学术界争论的问题。怎样既能通过积极治疗快速缓解病情,又避免过度化疗带来的副作用？本文对此争论作一讨论,以期得出明确的观点,指导临床工作。     

Doc, what would you do if you were me? On self-other discrepancies in medical decision making

Doctors often make decisions for their patients and predict their patients' preferences and decisions to customize advice to their particular situation. We investigated how doctors make decisions about medical treatments for their patients and themselves and how they predict their patients' decisions. We also studied whether these decisions and predictions coincide with the decisions that the patients make for themselves. We document 3 important findings. First, doctors made more conservative decisions for their patients than for themselves (i.e., they more often selected a safer medical treatment). Second, doctors did so even if they accurately predicted that their patients would want a riskier treatment than the one they selected. Doctors, therefore, showed substantial self-other discrepancies in medical decision making and did not make decisions that accurately reflected their patients' preferences. Finally, patients were not aware of these discrepancies and thought that the decisions their doctors made for themselves would be similar to the decisions they made for their patients. We explain these results in light of 2 current theories of self-other discrepancies in judgment and decision making: the risk-as-feelings hypothesis and the cognitive hypothesis. Our results have important implications for research on expert decision making and for medical practice, and shed some light on the process underlying self-other discrepancies in decision making.     

Life Trajectories, Genetic Testing, and Risk Reduction Decisions in 18–39 Year Old Women at Risk for Hereditary Breast and Ovarian Cancer

This qualitative study identified four life trajectories that influenced the decision in young women to have genetic testing for mutations in BRCA1/2 and subsequent risk reduction decisions after receiving a positive mutation result. Fifty nine women between the ages of 18–39 years were interviewed in this grounded theory study, 44 of those tested were found to have a mutation in either BRCA1 or BRCA2. Of those with a mutation, 23 had no history of cancer and 21 had a breast cancer diagnosis. Analysis of the 44 participants tested found that risk reducing decisions were related to the life trajectories that preceded genetic testing. These life trajectories included: 1) Long-standing awareness of breast cancer in the family, 2) Loss of one’s mother to breast cancer at a young age, 3) Expression of concern by a health care provider, and 4) Personal diagnosis of breast cancer. Understanding possible influences behind decision making for genetic testing and risk reduction in young women may assist health care providers in offering age appropriate guidance and support.     

Patient Motivation, Satisfaction, and Coping in Genetic Counseling and Testing for BRCA1 and BRCA2

Women with a strong family history of breast and/or ovarian cancer can now have genetic testing, that may identify mutations associated with increased cancer predisposition. Within the context of a clinical trial evaluating printed educational materials, we examined motivation, satisfaction, coping, and perceptions of genetic counseling and testing among 159 women who underwent pretest counseling and made a testing decision. Ninety-six percent of the participants elected to have BRCA1/2 testing. When making a decision about genetic testing, study participants were concerned less about the potential negative effects that could result from testing than the potential benefits. After counseling, participants said that they felt better able to make decisions that were right for them and that their questions and concerns were adequately addressed during the session. Ninety-five percent of the women were satisfied with their test decision. Participants used a range of strategies to cope with thoughts and feelings about cancer and/or genetic testing immediately following test decision. Results suggest that the genetic counseling session helped women make decisions about testing for BRCA1 and BRCA2, even in the setting of a trial in which all women also received detailed educational materials. Further, the results indicate that future research focusing on perceptions of risks and benefits of testing and of coping strategies immediately following test decision may be warranted.     

Why older adults make more immediate treatment decisions about cancer than younger adults

Literature relevant to medical decision making was reviewed, and a model was outlined for testing. Two studies examined whether older adults make more immediate decisions than younger adults about treatments for prostate or breast cancer in authentic scenarios. Findings clearly showed that older adults were more likely to make immediate decisions than younger adults. The research is important because it not only demonstrates the consistency of this age-related effect across disease domains, gender, ethnic groups, and prevalent education levels but begins to investigate a model to explain the effect. Major reasons for the effect focus on treatment knowledge, interest and engagement, and cognitive resources. Treatment knowledge, general cancer knowledge, interest, and cognitive resources relate to different ways of processing treatment information and preferences for immediate versus delayed decision making. Adults with high knowledge of treatments on a reliable test tended to make immediate treatment decisions, which supports the knowledge explanation. Adults with more cognitive resources and more interest tended to delay their treatment decisions. Little support was found for a cohort explanation for the relationship between age and preference for immediate medical decision making.     

Doctors' decision-making on giving information to cancer patients

A major focus in the literature about doctor-patient communication is information-giving. In the case of cancer patients, one significant issue is which factors determine whether and how, general practitioners and oncologists give information to their patients. Whatever may be the content of information, the most important choice for the doctor is to give information or not. Our research group at the Department of Health Psychology has conducted investigations in order to identify the significant determinants of decisions concerning giving information to cancer patients. A sample of 60 doctors from Alicante province in Spain were asked their criteria for giving information about a cancer diagnosis. Results showed that perceived intelligence and emotional control in the patients were the best predictors of the decision by doctors to give information. Age and socio-economic status were also significantly associated with the doctors' information-giving practices. These data suggest that the criteria for giving information to cancer patients are subjective and show a strong cultural influence.     

前景理论在重症医学临床决策中的应用

临床决策是每一个医生每天面临的工作,正确的临床决策不仅可以带给患者较好的结果,同时也可以让医生与患者及家属沟通更加良好。本文首先论述了重症医学的临床决策特点,每一个救治方案的收益与损失的权衡不仅仅是取决于患者病情,而且与决策者的风险偏好有明显关系。为了更好地解决这个问题,把诺贝尔奖获奖者丹尼尔的前景理论引入到重症患者的...     

Doctors' decision-making on giving information to cancer patients

Abstract

A major focus in the literature about doctor-patient communication is information-giving. In the case of cancer patients, one significant issue is which factors determine whether and how, general practitioners and oncologists give information to their patients. Whatever may be the content of information, the most important choice for the doctor is to give information or not. Our research group at the Department of Health Psychology has conducted investigations in order to identify the significant determinants of decisions concerning giving information to cancer patients. A sample of 60 doctors from Alicante province in Spain were asked their criteria for giving information about a cancer diagnosis. Results showed that perceived intelligence and emotional control in the patients were the best predicotrs of the decision by doctors to give information. Age and socio-economic status were also significantly associated with the doctors' information-giving practices. These data suggest that the criteria for giving information to cancer patients are subjective and show a strong cultural influence.     

蒽环类耐药转移性乳腺癌的治疗现状与思考

蒽环类药物是治疗乳腺癌最有效的化疗药物之一,但蒽环类耐药后乳腺癌可发生复发或转移,而转移性乳腺癌仍然提倡以化疗为主的综合治疗。肿瘤学工作者应以循证医学为指导,合理选择化疗方案,注重个体化治疗,才能在蒽环类耐药转移性乳腺癌的治疗上取得新突破。     

Increasing Career Self‐Efficacy for Women: Evaluating a Group Intervention

The study evaluated whether women participating in a career group designed to increase career‐related self‐efficacy would make gains on career decision‐making self‐efficacy and vocational exploration and commitment compared with women in a control group. Thirty‐one women participated in a 6‐week treatment group, and 30 women participated in a no‐treatment control group. Results indicated that, compared with the control group, women in the treatment group improved on career decision‐making self‐efficacy and vocational exploration and commitment, and maintained those gains at 6‐week follow‐up. The discussion focuses on implications for counseling, limitations of the study, and future research.