1. 概述

恶性肿瘤是我国最常见的死亡原因之一。虽然随着医学技术的进步肿瘤患者5年生存率已有明显提高，达40%。由于长期的肿瘤本身的消耗以及在肿瘤治疗中可能产生不良反应等会严重影响患者的生存时间和生活质量。因此，在提高生存率的同时，改善患者的生存质量同样非常重要。肿瘤支持治疗是以优化肿瘤患者全程管理、各种症状控制为目标，对肿瘤相关症状及抗肿瘤相关不良反应进行药物和非药物干预的治疗方法。本文旨在对最新的肿瘤支持治疗相关内容的进展进行总结和展望，希望能引发各位临床工作者及科研工作对肿瘤患者支持治疗的关注与思考。

第三章肿瘤支持治疗学科发展趋势和展望

1. 长效G-CSF对化疗导致的中性粒细胞减少的未来发展方向

随着长效G-CSF在多种不同化疗方案，多个瘤种中的疗效和安全性得到证实，其应用也会越来越广泛。加上长效G-CSF注射次数少，半量预防效果与足量无显著差异等优势，其可能会取代短效G-CSF成为首选的预防及治疗CIN的药物。但在此之前，长效G-CSF在不同瘤种中的效果和安全性仍需要进一步研究。同时，长效G-CSF也受到其他药物的挑战，我国学者参与的对比普那布林与长效G-CSF在乳腺癌，非小细胞肺癌，前列腺癌等应用多西他赛的患者在预防CIN上效果的三期临床试验显示，普那布林在严重粒细胞减少的持续时间上不劣于长效G-CSF，且在骨痛（P=0.01）和血小板减少症（P<0.0001)等不良反应的发生率更低。这意味着有更多药物可用于CIN的治疗及预防，而后续对于各类药物的适应症和规范化使用，以及进一步探索其他药物对CIN的作用都是值得后续进一步地探索。

2. 免疫治疗相关不良反应研究未来发展方向

随着ICIs临床适应症不断拓展，伴随而来的irAEs也越来越受到关注和重视。在未来的诊疗工作中，准确地识别ICIs治疗的最佳获益患者，更好地了解irAEs的潜在机制和危险因素，提前预测irAEs的发生，有助于提高ICIs治疗疗效并减少毒副反应，改善癌症患者的预后和生活质量。

展望2025年，irAEs未来研究方向将聚焦于个体化治疗策略的开发，通过基于遗传学、微生物组和免疫微环境特征的irAE风险预测模型，实现治疗前的精准分层管理；探索新型组织特异性免疫调节剂，如靶向CXCR6+ T细胞或IL-21通路的药物，以在控制irAE的同时保留抗肿瘤免疫反应；建立多学科随访体系，重点监测心血管事件、生育力损伤及继发肿瘤风险，并完善患者教育支持；随着TCR-T细胞疗法在实体瘤治疗中取得突破，需系统评估其独特毒性谱及与ICIs的差异；此外，推动全球协作与数据共享，开展大规模前瞻性临床试验统一irAE的定义与评估标准，以优化治疗指南的推荐^[86]。

3. 癌痛研究未来发展方向

多学科诊疗（MDT）制度结合药物、心理和物理治疗的综合模式，将有助于提升癌痛患者的生活质量^[87]。为了更好地开展疼痛综合管理，多家医院在今年建立了疼痛诊疗综合平台。然而，目前我国医疗资源有限，癌痛患者在出院后往往缺乏规范的治疗指导。值得庆幸的是，随着科技的飞速发展，新技术应用为癌痛管理带来了新的机遇。有研究表明，AI可以对大量的癌痛患者数据进行分析，挖掘其中的规律，预测患者的疼痛模式，提前采取相应的干预措施^[88]。比如，10分钟的沉浸式VR分散疗法较二维引导意象分散疗法治疗中重度癌痛患者，更能使患者在干预后疼痛显著改善^[89]。

4. 肿瘤患者营养治疗未来发展方向

营养不良往往跟肿瘤较晚的分期以及较差的预后相关，目前各大指南对肿瘤患者营养风险和营养状态的评估依然停留在泛癌种分析上，对不同肿瘤特征性的营养风险筛选以及营养状态评估仍缺乏研究。近年来，机器学习以及人工智能的发展给营养风险筛查和营养状态评估提供了新思路，能更早的筛查出有营养风险的患者并及时干预。然而对于个体化的营养风险筛查，仍需要临床工作者和研究者针对各类癌症的特征，进行筛查工具的进一步精细化、专门化。

除此之外，关于肿瘤的营养治疗，目前各大指南的建议仍缺乏针对不同类型的肿瘤个体化、精准化推荐。不同的肿瘤具有不同的消耗特征，如何让营养治疗在不同肿瘤患者中均实现效益最大化，仍是目前需要研究的方向。

营养支持治疗是肿瘤综合治疗中的重要部分之一，营养支持治疗配合适当的运动计划，可有效地阻止肿瘤患者体内肌肉流失，改善患者体能状态，从而显著改善癌症患者的预后。然而，营养治疗不仅仅是一个在医院的过程，更需要患者和家属在日常生活中的配合，如何普及相关知识，如何医患共同配合改善营养，都需要我们在未来的临床实践中进一步探索。

5. 放射性肺损伤的未来发展方向

放射性肺损伤（RILI）是临床胸部放射治疗中主要的剂量限制性毒性之一，大约 10-20% 的患者表现出不同严重程度的 RILI 体征。RILI 的发生机制目前尚不完全清楚。放射治疗技术的进步和严格的危及器官剂量限制的使用有助于减少 RILI。通过整合临床特征、剂量学因素、遗传易感性以及外周血生物标志物将进一步提高对RILI的预测能力。目前仍缺乏 RILI 的客观定义，通过使用 CT 密度测定、FDG-PET 摄取、肺功能测量变化或呼出气分析等工具将更好地定义和量化 RILI。通过组学技术、（单细胞）RNA 测序和质谱流式分析以及患者特异性体外细胞培养模型有助于寻找新的生物标志物， RILI 的客观量化与这些新技术相结合，可以帮助开发更多的生物标志物，以更好地预测哪些患者面临风险，并做出个性化的治疗决策。

6. NSCLC脑转移的未来发展方向

虽然肺癌脑转移风险预测取得了一定的进展，但是目前临床实践中暂时缺乏理想可靠的指标或风险模型。总的来说，2024年NSCLC脑转移领域的多维度进展为患者带来了更多希望，也为未来的研究和治疗指明了方向。

7. 恶液质的未来发展方向

早期诊断和营养及代谢支持治疗可能逆转肿瘤恶液质状态，进而改善患者的临床结局。对肿瘤恶液质患者，除了积极的抗肿瘤治疗，多学科、多模式联合方式（包括肿瘤内外科、营养治疗、心理干预等）和早期干预是预防、逆转恶液质状态、延缓肿瘤疾病进展的关键举措。同时，根据患者的个体特征预测治疗反应和预后，提供精准的综合治疗策略。未来，应制定治疗肿瘤恶液质的有效、标准化诊治指南，在循证医学基础上，多学科诊疗小组领导下综合治疗是肿瘤恶液质的最佳治疗模式。未来需开展III期试验验证长期疗效，并探索与其他抗肿瘤药物的联合应用策略。

第四章总结

支持对于肿瘤患者具有重大的意义，与世界发达地区相比，我国的肿瘤支持治疗起步相对较晚，远远未满足患者需要。虽然目前在支持治疗的各个领域均有一定的实践和研究，但尚未形成整体概念和体系，未来针对肿瘤患者的支持治疗的个体化、精准化相关研究依然有很大的探索空间。

【主编】

袁响林华中科技大学同济医学院附属同济医院

【副主编】

张俊上海交通大学医学院附属瑞金医院

张小田北京大学肿瘤医院

熊建萍南昌大学第一附属医院

王风华中山大学附属肿瘤医院

章真复旦大学肿瘤医院

【编委】（按姓氏拼音排序）

邓军南昌大学第一附属医院

谷雨复旦大学附属肿瘤医院

关文龙中山大学肿瘤防治中心

李龙华中科技大学同济医学院附属同济医院

宁涛天津医科大学肿瘤医院

夏曙华中科技大学同济医学院附属同济医院

余昕南昌大学第一附属医院

朱博韬北京大学肿瘤医院

赵丽琴上海交通大学医学院附属瑞金医院

★

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