肺癌患者同步放化疗癌因性疲乏潜在剖面分析及影响因素研究

doi:10.3877/cma.j.issn.1674-6902.2026.01.008

目的

探讨肺癌患者同步放化疗癌因性疲乏的潜在剖面特征及影响因素。

方法

选取2020年1月至2024年12月我院收治的接受同步放化疗肺癌患者117例为对象，根据癌因性疲乏类别分为3组，轻度疲乏34例为轻度组、中度疲乏56例为中度组、重度疲乏27例为重度组。采用癌因性疲乏量表(cancer fatigue scale, CFS)、匹兹堡睡眠质量指数(Pittsburgh sleep quality index, PSQI)、社会支持评定量表(social support rating scale, SSRS)、医院焦虑抑郁量表(hospital anxiety and depression scale, HADS)及营养风险筛查工具(nutritional risk screening 2002, NRS-2002)进行调查。运用潜在剖面分析(latent profile analysis, LPA)识别癌因性疲乏潜在类别，采用Logistic回归分析影响因素。

结果

轻度、中度、重度组患者CFS身体疲乏、情感疲乏、认知疲乏及总分差异有统计学意义(P<0.001)；三组患者年龄、病程、营养风险、睡眠质量、社会支持、焦虑、抑郁及KPS评分差异有统计学意义(P<0.05)。Logistic回归分析显示，年龄(OR＝1.10，95%CI：1.03~1.16)、病程(OR＝1.15，95%CI：1.05~1.26)、营养风险(OR＝1.83，95%CI：1.28~2.62)、睡眠质量(OR＝1.17，95%CI：1.06~1.30)、焦虑(OR＝1.19，95%CI：1.05~1.36)、C反应蛋白(C-reactive protein, CRP)(OR＝1.07，95%CI：1.03~1.12)、白细胞介素-6(interleukin-6, IL-6)(OR＝1.12，95%CI：1.03~1.22)及细胞角蛋白19片段(cytokeratin 19 fragment, CYFRA21-1)(OR＝1.13，95%CI：1.04~1.23)为肺癌同步放化疗期癌因性疲乏危险因素，KPS评分(OR＝0.94，95%CI：0.89~0.98)、血红蛋白(OR＝0.96，95%CI：0.93~0.99)及白蛋白水平(OR＝0.93，95%CI：0.87~0.99)为保护因素。

结论

肺癌同步放化疗期癌因性疲乏呈现分层特征，年龄增加、病程延长、营养风险高、睡眠质量差、焦虑症状明显及CRP、IL-6和CYFRA21-1升高与疲乏程度加重相关。

关键词: 支气管肺癌, 同步放化疗, 癌因性疲乏, 潜在剖面分析, 影响因素

Objective

To investigate the latent profile characteristics and influencing factors of cancer-related fatigue in lung cancer patients undergoing concurrent chemoradiotherapy.

Methods

A total of 117 lung cancer patients who received concurrent chemoradiotherapy in our hospital from January 2020 to December 2024 were selected and divided into three groups based on the degree of cancer-related fatigue: mild group 34 cases, moderate group 56 cases, and severe group 27 cases. Surveys were conducted using the Cancer Fatigue Scale (CFS), Pittsburgh Sleep Quality Index (PSQI), Social Support Rating Scale (SSRS), Hospital Anxiety and Depression Scale (HADS), and Nutritional Risk Screening 2002 (NRS-2002). Latent Profile Analysis (LPA) was employed to identify potential categories of cancer-related fatigue, and logistic regression was used to analyze the influencing factors.

Results

There were statistically significant differences among the mild, moderate, and severe groups in terms of CFS physical fatigue, emotional fatigue, cognitive fatigue, and total scores (P<0.001). Statistically significant differences were also observed among the three groups in age, disease duration, nutritional risk, sleep quality, social support, anxiety, depression, and Karnofsky Performance Status (KPS) scores (P<0.05). Logistic regression analysis showed that age (OR=1.10, 95%CI: 1.03~1.16), disease duration (OR=1.15, 95%CI: 1.05~1.26), nutritional risk (OR=1.83, 95%CI: 1.28~2.62), sleep quality (OR=1.17, 95%CI: 1.06~1.30), anxiety (OR=1.19, 95%CI: 1.05~1.36), C-reactive protein (CRP) (OR=1.07, 95%CI: 1.03~1.12), interleukin-6 (IL-6) (OR=1.12, 95%CI: 1.03~1.22), and cytokeratin 19 fragment (CYFRA21-1) (OR=1.13, 95%CI: 1.04~1.23) were risk factors for cancer-related fatigue in lung cancer patients undergoing concurrent chemoradiotherapy. KPS score (OR=0.94, 95%CI: 0.89~0.98), hemoglobin level (OR=0.96, 95%CI: 0.93~0.99), and albumin level (OR=0.93, 95%CI: 0.87~0.99) were protective factors.

Conclusion

Cancer-related fatigue in lung cancer patients undergoing concurrent chemoradiotherapy exhibits hierarchical characteristics. Increased age, longer disease duration, higher nutritional risk, poor sleep quality, significant anxiety symptoms, and elevated levels of CRP, IL-6, and CYFRA21-1 are associated with more severe fatigue.

Key words: Bronchogenic carcinoma, Concurrent chemoradiotherapy, Cancer-related fatigue, Latent profile analysis, Influencing factors

表1 癌因性疲乏类别的潜在剖面结果分析

模　型	AIC	BIC	SABIC	熵值	LMRT P值	BLRT P值	类别比例
1类	2 728.51	2 776.34	2 741.22
2类	2 618.47	2 681.26	2 635.09	0.834	0.006	0.000	0.612/0.388
3类	2 546.38	2 612.74	2 568.59	0.857	0.024	0.000	0.291/0.479/0.230
4类	2 538.41	2 622.86	2 561.33	0.869	0.137	0.072	0.106/0.348/0.291/0.255

表1 癌因性疲乏类别的潜在剖面结果分析

模　型	AIC	BIC	SABIC	熵值	LMRT P值	BLRT P值	类别比例
1类	2 728.51	2 776.34	2 741.22
2类	2 618.47	2 681.26	2 635.09	0.834	0.006	0.000	0.612/0.388
3类	2 546.38	2 612.74	2 568.59	0.857	0.024	0.000	0.291/0.479/0.230
4类	2 538.41	2 622.86	2 561.33	0.869	0.137	0.072	0.106/0.348/0.291/0.255

表2 肺癌患者轻度、中度和重症疲乏临床资料结果比较

临床资料	变　量	轻度疲乏(n＝34)	中度疲乏(n＝56)	重度疲乏(n＝27)	统计值χ²/t值	P值
年龄(岁)[n(%)]	<60	11(32.35)	13(23.21)	4(14.81)	6.020	0.049
	60~70	16(47.06)	26(46.43)	11(40.74)
	>70	7(20.59)	17(30.36)	12(44.44)
文化程度[n(%)]	初中及以下	13(38.24)	30(53.57)	21(77.78)	9.840	0.008
	高中/中专	12(35.29)	17(30.36)	4(14.81)
	大专及以上	9(26.47)	9(16.07)	2(7.41)
婚姻状况[n(%)]	已婚	31(91.18)	44(78.57)	19(70.37)	6.470	0.039
	其他	3(8.82)	12(21.43)	8(29.63)
病理类型[n(%)]	NSCLC	31(91.18)	49(87.50)	23(85.19)	0.630	0.732
	SCLC	3(8.82)	7(12.50)	4(14.81)
TNM分期[n(%)]	Ⅲ期	28(82.35)	36(64.29)	13(48.15)	8.710	0.013
	Ⅳ期	6(17.65)	20(35.71)	14(51.85)
治疗周期[n(%)]	1~2周期	8(23.53)	17(30.36)	11(40.74)	6.010	0.049
	3~4周期	17(50.00)	27(48.21)	10(37.04)
	≥5周期	9(26.47)	12(21.43)	6(22.22)
实验室指标(±s)	血红蛋白(g/L)	128.43±16.21	121.34±17.53	112.58±18.07	8.120	0.001
	白蛋白(g/L)	41.18±3.79	38.62±4.08	36.92±4.47	9.070	0.000
	CRP(mg/L)	7.82±6.19	12.86±9.13	19.63±11.79	10.240	0.000
	IL-6(pg/ml)	5.18±3.91	7.63±5.09	10.41±6.28	7.010	0.001
	TNF-α(pg/ml)	9.12±3.97	10.76±4.48	13.18±5.12	5.130	0.008
	CEA(ng/ml)	4.08±3.68	5.17±4.41	6.29±5.06	2.120	0.126
	CYFRA21-1(ng/ml)	3.36±2.58	4.73±3.47	6.06±4.23	4.620	0.017
	NSE(ng/ml)	16.47±8.72	18.21±9.09	19.58±9.84	0.900	0.410
	ProGRP(pg/ml)	63.28±51.86	72.44±60.12	88.21±70.84	1.380	0.255
	Na^＋(mmol/L)	139.18±3.17	138.73±3.62	138.06±3.83	0.920	0.403
	K^＋(mmol/L)	4.11±0.39	4.06±0.42	3.98±0.44	1.210	0.302
	肌酐(μmol/L)	69.86±18.24	71.72±19.08	74.19±20.93	0.290	0.749
	ALT(U/L)	26.31±13.92	28.14±15.84	31.76±17.93	1.640	0.198

表2 肺癌患者轻度、中度和重症疲乏临床资料结果比较

临床资料	变　量	轻度疲乏(n＝34)	中度疲乏(n＝56)	重度疲乏(n＝27)	统计值χ²/t值	P值
年龄(岁)[n(%)]	<60	11(32.35)	13(23.21)	4(14.81)	6.020	0.049
	60~70	16(47.06)	26(46.43)	11(40.74)
	>70	7(20.59)	17(30.36)	12(44.44)
文化程度[n(%)]	初中及以下	13(38.24)	30(53.57)	21(77.78)	9.840	0.008
	高中/中专	12(35.29)	17(30.36)	4(14.81)
	大专及以上	9(26.47)	9(16.07)	2(7.41)
婚姻状况[n(%)]	已婚	31(91.18)	44(78.57)	19(70.37)	6.470	0.039
	其他	3(8.82)	12(21.43)	8(29.63)
病理类型[n(%)]	NSCLC	31(91.18)	49(87.50)	23(85.19)	0.630	0.732
	SCLC	3(8.82)	7(12.50)	4(14.81)
TNM分期[n(%)]	Ⅲ期	28(82.35)	36(64.29)	13(48.15)	8.710	0.013
	Ⅳ期	6(17.65)	20(35.71)	14(51.85)
治疗周期[n(%)]	1~2周期	8(23.53)	17(30.36)	11(40.74)	6.010	0.049
	3~4周期	17(50.00)	27(48.21)	10(37.04)
	≥5周期	9(26.47)	12(21.43)	6(22.22)
实验室指标(±s)	血红蛋白(g/L)	128.43±16.21	121.34±17.53	112.58±18.07	8.120	0.001
	白蛋白(g/L)	41.18±3.79	38.62±4.08	36.92±4.47	9.070	0.000
	CRP(mg/L)	7.82±6.19	12.86±9.13	19.63±11.79	10.240	0.000
	IL-6(pg/ml)	5.18±3.91	7.63±5.09	10.41±6.28	7.010	0.001
	TNF-α(pg/ml)	9.12±3.97	10.76±4.48	13.18±5.12	5.130	0.008
	CEA(ng/ml)	4.08±3.68	5.17±4.41	6.29±5.06	2.120	0.126
	CYFRA21-1(ng/ml)	3.36±2.58	4.73±3.47	6.06±4.23	4.620	0.017
	NSE(ng/ml)	16.47±8.72	18.21±9.09	19.58±9.84	0.900	0.410
	ProGRP(pg/ml)	63.28±51.86	72.44±60.12	88.21±70.84	1.380	0.255
	Na^＋(mmol/L)	139.18±3.17	138.73±3.62	138.06±3.83	0.920	0.403
	K^＋(mmol/L)	4.11±0.39	4.06±0.42	3.98±0.44	1.210	0.302
	肌酐(μmol/L)	69.86±18.24	71.72±19.08	74.19±20.93	0.290	0.749
	ALT(U/L)	26.31±13.92	28.14±15.84	31.76±17.93	1.640	0.198

图1 不同癌因性疲乏潜在剖面患者同步放化疗前后胸部CT典型影像学表现。图A、B为治疗前后轻度组典型病例胸部CT图；图C、D为治疗前后重度组典型病例胸部CT图

表3 不同疲乏剖面患者综合状态评分结果比较(

±s)

综合状态	轻度疲乏(n＝34)	中度疲乏(n＝56)	重度疲乏(n＝27)	F值	P值
病程(月)	4.68±2.93	7.76±4.41	10.37±5.58	8.65	0.000
NRS-2002评分	2.47±1.23	3.38±1.46	4.29±1.83	6.71	0.002
PSQI总分	6.42±3.07	8.56±3.45	10.68±4.21	5.88	0.004
SSRS总分	43.12±8.84	39.65±8.97	35.64±8.93	4.96	0.008
HADS-焦虑	6.18±3.12	8.07±3.36	9.63±4.18	4.31	0.015
HADS-抑郁	5.35±2.83	7.28±3.57	8.54±3.73	3.87	0.023
KPS评分	84.32±9.54	77.42±10.25	71.58±10.97	7.08	0.001

表3 不同疲乏剖面患者综合状态评分结果比较(

±s)

综合状态	轻度疲乏(n＝34)	中度疲乏(n＝56)	重度疲乏(n＝27)	F值	P值
病程(月)	4.68±2.93	7.76±4.41	10.37±5.58	8.65	0.000
NRS-2002评分	2.47±1.23	3.38±1.46	4.29±1.83	6.71	0.002
PSQI总分	6.42±3.07	8.56±3.45	10.68±4.21	5.88	0.004
SSRS总分	43.12±8.84	39.65±8.97	35.64±8.93	4.96	0.008
HADS-焦虑	6.18±3.12	8.07±3.36	9.63±4.18	4.31	0.015
HADS-抑郁	5.35±2.83	7.28±3.57	8.54±3.73	3.87	0.023
KPS评分	84.32±9.54	77.42±10.25	71.58±10.97	7.08	0.001

1	Harðardottir H, Jonsson S, Gunnarsson O, et al. [Advances in lung cancer diagnosis and treatment-a review][J]. Laeknabladid, 2022, 108(1): 17-29.
2	Brody H. Lung cancer[J]. Nature, 2020, 587(7834): S7.
3	Thong MSY, van NoordenCJF, Steindorf K, et al. Cancer-related fatigue: Causes and current treatment options[J]. Curr Treat Options Oncol, 2020, 21(2): 17.
4	刘志静，马婧，王利颖，等. 终末期肺癌患者癌因性疲乏及影响因素分析[J/OL]. 中华肺部疾病杂志(电子版), 2025, 18(2): 310-314.
5	韩江英，段培蓓，王芳，等. 癌因性疲乏中西医结合护理专家共识[J]. 临床护理杂志，2025, 24(4): 12-17.
6	Voorn MJJ, Driessen EJM, Reinders R, et al. Effects of exercise prehabilitation and/or rehabilitation on health-related quality of life and fatigue in patients with non-small cell lung cancer undergoing surgery: A systematic review [J]. Eur J Surg Oncol, 2023, 49(10): 106909.
7	Bade BC, Faiz SA, HaD M, et al. Cancer-related fatigue in lung cancer: A research agenda: An official American thoracic society research statement [J]. Am J Respir Crit Care Med, 2023, 207(5): e6-e28.
8	尹奎，彭坚，张君. 潜在剖面分析在组织行为领域中的应用[J]. 心理科学进展，2020, 28(7): 1056-1070.
9	Okuyama T, Akechi T, Kugaya A, et al. Development and validation of the cancer fatigue scale A brief，three-dimensional，self-rating scale for assessment of fatigue in cancer patients[J]. J Pain Sympt Managem, 2000, 19(1): 5-14.
10	Sosna J. Is recist version 1.1 reliable for tumor response assessment in metastatic cancer? [J]. Radiology, 2019, 290(2): 357-358.
11	Herranz-gómez A, Cuenca-martínez F, Suso-martí L, et al. Effectiveness of therapeutic exercise models on cancer-related fatigue in patients with cancer undergoing chemotherapy: A systematic review and network Meta-analysis [J]. Arch Phys Med Rehabil, 2023, 104(8): 1331-1342.
12	Robinson C, Feder G, Huntley AL, et al. Validation of the cancer fatigue scale (CFS) in a UK population [J]. BMC Cancer, 2025, 25(1): 1394.
13	Poopady A, Nayak S, D′silva F, et al. Cancer related fatigue measurement scales: A systematic review[J]. Indian J Public Health, 2023, 67(3): 448-454.
14	Zhou Z, Yang Y, Sun J, et al. Heterogeneity of pain-fatigue-sleep disturbance symptom clusters in lung cancer patients after chemotherapy: a latent profile analysis [J]. Support Care Cancer, 2024, 32(12): 821.
15	Park JH, Chun M, Bae SH, et al. Latent profile analysis for assessing symptom clusters in women with breast cancer[J]. J Cancer Surviv, 2024, doi: 10.1007/s11764-024-01648-6.
16	Li Y, Yan B, He S. Advances and challenges in the treatment of lung cancer[J]. Biomed Pharmacother, 2023, 169: 115891.
17	Horino T, Tokunaga R, Miyamoto Y, et al. The impact of the advanced lung cancer inflammation index on the outcomes of patients with metastatic colorectal cancer who receive chemotherapy[J]. Int J Clin Oncol, 2023, 28(3): 400-408.
18	Ma Y, He B, Jiang M, et al. Prevalence and risk factors of cancer-related fatigue: A systematic review and meta-analysis[J]. Int J Nurs Stud, 2020, 111: 103707.
19	Nowe E, Stöbel-Richter Y, Sender A, et al. Cancer-related fatigue in adolescents and young adults: A systematic review of the literature[J]. Crit Rev Oncol Hematol, 2017, 118: 63-69.
20	Tsou YL, Lee JM, Tang CC. The trajectory of cancer-related fatigue and its associating factors in patients with esophageal cancer receiving treatments: A prospective longitudinal study[J]. Ann Surg Oncol, 2022, 29(5): 2784-2790.
21	Li M, Zhang Y, Liu J, et al. Complementary and alternative medicine：A narrative review of nutritional approaches for cancer-related fatigue[J]. Medicine (Baltimore), 2024, 103(11): e37480.
22	中华医学会肿瘤学分会肿瘤支持康复治疗学组. 中国癌症相关性疲乏临床实践诊疗指南(2021年版)[J]. 中国癌症杂志，2021, 31(9): 852-872.
23	Sheng Jin, Pan Hongming. Comments on NCCN guidelines for diagnosis and treatment of cancer-related fatigue, version 2.2023[J]. J Pract Oncol, 2023, 38(5): 416-420.
24	Ee C, Kay S, Reynolds A, et al. Lifestyle and integrative oncology interventions for cancer-related fatigue and sleep disturbances[J]. Maturitas, 2024, 187: 108056.
25	徐琴鸿，林郁清，陈秋慧. 癌症患者睡眠质量与恐惧疾病进展的相关性研究[J]. 中华现代护理杂志，2018, 24(12): 1399-1402.
26	Dun L, Xian-Yi W, Si-Ting H, et al. Effects of sleep interventions on cancer-related fatigue and quality of life in cancer patients: a systematic review and meta-analysis[J]. Support Care Cancer, 2022, 30(4): 3043-3055.
27	李钦钦，孙小淋，徐洁. 肺癌首次化疗患者癌因性疲乏现状及其与希望水平、社会支持、心理弹性的相关性研究[J]. 心理月刊，2025, 20(10): 44-46.
28	李海军，王扶娟，杨其洲，等. 癌症病人疲乏与社会支持相关性的Meta分析[J]. 循证护理，2023, 9(18): 3277-3282.
29	刘慧，柳莹，施海彬. 肝癌介入术后癌因性疲乏与术前焦虑抑郁的相关性[J]. 国际精神病学杂志，2025, 52(3): 948-950＋974.
30	Zhu L, Yao J, Wang J, et al. The predictive role of self-compassion in cancer patients′symptoms of depression，anxiety，and fatigue: a longitudinal study[J]. Psychooncology, 2019, 28(9): 1918-1925.
31	Schellekens MPJ, Wolvers MDJ, Schroevers MJ, et al. Exploring the interconnectedness of fatigue，depression，anxiety and potential risk and protective factors in cancer patients：a network approach[J]. J Behav Med, 2020, 43(4): 553-563.
32	张蕊，李敏，饶建玲. 肺癌患者癌因性疲乏现状及影响因素分析[J/OL]. 中华肺部疾病杂志(电子版), 2024, 17(1): 111-114.

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Study on latent profile analysis of cancer-related fatigue and its influencing factors in lung cancer patients undergoing concurrent chemoradiotherapy

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Study on latent profile analysis of cancer-related fatigue and its influencing factors in lung cancer patients undergoing concurrent chemoradiotherapy