Interventionen in der Rehabilitation von Mammakarzinompatientinnen - Eine methodenkritische Übersicht zum Forschungsstand

 

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Zusammenfassung

Durch den Förderschwerpunkt „Rehabilitationswissenschaften” des Bundesforschungsministeriums und der Deutschen Rentenversicherung sowie durch ein umfangreiches Qualitätssicherungsprogramm der gesetzlichen Rentenversicherung konnte der wissenschaftliche Kenntnisstand in der Rehabilitation im Hinblick auf Struktur-, Prozess- oder Ergebnismerkmale deutlich verbessert werden. In Weiterführung der systematischen Erfassung und Bewertung des zunehmenden Wissens wurde seitens der Rentenversicherungsträger ein umfassendes Leitlinienprogramm zur Erstellung von Prozessleitlinien in der Rehabilitation initiiert. Im Rahmen dieses Förderprogramms werden exemplarisch für die onkologische Rehabilitation auch Leitlinien für die Rehabilitation von Patientinnen mit einer Brustkrebserkrankung erarbeitet. Dieser Artikel fasst die Ergebnisse der ersten Phase dieses Projektes zusammen, in der eine systematische Literaturanalyse der Interventionen in der Rehabilitation von Brustkrebspatientinnen durchgeführt wurde mit dem Ziel, die Evidenzbasierung in diesem Bereich zu prüfen und spezifische Empfehlungen für die Behandlung im Rahmen der stationären Rehabilitation ableiten zu können. Dazu wurden die vorliegenden nationalen und internationalen Leitlinien zur Behandlung des Mammakarzinoms analysiert sowie eine systematische Literatursuche in den gängigen Datenbanken (Medline, Psyndex, PsycINFO, CINAHL, DIMDI und EBMR) durchgeführt. Es wurden ambulante und stationäre Interventionen einbezogen, während diagnostische Verfahren, Medikamentenstudien, ärztlich-medizinische und pflegerische Maßnahmen nicht Gegenstand dieser Analyse waren. Insgesamt konnten aus einer Gesamtzahl von 480 317 Artikeln ca. 200 letztendlich zur systematischen Analyse extrahiert werden. Diese Artikel werden analysiert und entsprechend der Evidenz nach den Oxford Levels of Evidence bewertet. Aufgrund der Literaturanalyse konnten verschiedene Interventionen für Mammakarzinompatientinnen wie Entspannungsverfahren, Physiotherapie, Sporttherapie, Massagen, Lymphdrainagen, psychosoziale Beratungen und Therapien sowie künstlerische Therapien als Behandlungsmodule konkretisiert werden. Die einzelnen Module unterscheiden sich erheblich hinsichtlich ihrer Evidenzbasierung. So konnten für Entspannungsverfahren, Sporttherapie und psychosoziale Beratung und Therapie gute Evidenzbasierungen, für Lymphdrainagen und künstlerische Therapien eher geringe Evidenzbasierungen gefunden werden. Zusammenfassend lässt sich feststellen, dass für die Interventionen in der Rehabilitation von Brustkrebspatientinnen eine Evidenzbasierung auf unterschiedlichen Stufen vorliegt. In einem nächsten Schritt wird zur Ausarbeitung von Behandlungsleitlinien eine systematische Expertenbefragung durchgeführt.

Abstract

On account of the „rehabilitation sciences” research funding programme of the German federal research ministry and the statutory German Pension Insurance scheme, as well as an extensive Pension Insurance quality assurance programme, major scientific progress has been achieved in rehabilitation in terms of structures, processes and outcomes. Continuing the systematic assessment and evaluation of the increasing knowledge available, the German Pension Insurance scheme has introduced a comprehensive practice guidelines programme for the development of process guidelines in rehabilitation. In the framework of this sponsored programme and exemplary for the field of cancer rehabilitation, practice guidelines are also being developed for the rehabilitation of breast cancer patients. This article summarises the results of the first phase of this project, which had included a systematic literature analysis of the interventions in the rehabilitation of breast cancer patients, an analysis aimed at verifying whether these interventions had been evidence-based as well as at deriving specific recommendations for treatment in the framework of in-patient rehabilitation. The existing national and international guidelines for the treatment of breast cancer were analysed for this purpose, and a systematic search of the established literature databases (Medline, Psyndex, PsycINFO, CINAHL, DIMDI and EBMR) was carried out. Both ambulatory and in-patient interventions were included, whereas diagnostic, medical and nursing procedures as well as drug trials were excluded from the analysis. In all, some 200 articles have eventually been extracted for systematic analysis from a total of 480,317 articles. The articles were analysed and evaluated according to the Oxford Level of Evidence. Various interventions for breast cancer patients could be validated as treatment modules by this literature analysis, such as: relaxation techniques, physiotherapy, sport therapy, massage, lymph drainage, psycho-social counselling and therapies as well as artistic therapies. There are considerable differences among the modules with respect to their various levels of evidence. Whereas good levels of evidence could be found for relaxation techniques, sport therapy and psycho-social counselling and therapy, only a low level of evidence was found for lymph drainage and artistic therapies. In summary, it can be stated that different levels of evidence are applicable concerning the various interventions available in the rehabilitation of breast cancer patients. The next step ahead toward development of treatment guidelines will involve systematic consultations with experts in this field.

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Prof. Dr. phil. Joachim Weis

Klinik für Tumorbiologie Freiburg

Breisacher Straße 117

79106 Freiburg

Email: weis@tumorbio.uni-freiburg.de