乳腺癌幸存者整合照护现状及服务困境的研究进展
Research Progress on the Current Situation and Service Predicaments of Integrated Care for Breast Cancer Survivors
摘要: 随着乳腺癌诊疗技术的不断进步和治疗水平的不断提高，乳腺癌幸存者的数量逐渐呈上升趋势，其在躯体、心理、社会和信息等多方面的照护需求日益凸显。以“疾病治疗为中心”的传统单一照护模式已难以满足乳腺癌幸存者连续性、多维度并贯穿全生命周期阶段的照护需求。因此，本研究将采用叙述性综述的方法，从临床整合、专业整合、组织整合和系统整合四个维度为切入点，围绕乳腺癌幸存者的照护需求、整合照护模式、服务供给现状及实践障碍方面进行综述，旨在梳理当前乳腺癌幸存者整合照护现状及困境，并提出针对性的改进建议，以期构建连续、协调及全面的乳腺癌幸存者整合照护模式提供参考。
Abstract: With continuous advances in breast cancer diagnosis and treatment technologies and ever-improving standards of care, the number of breast cancer survivors is gradually increasing, and their care needs—spanning physical, psychological, social and informational aspects—are becoming increasingly apparent. The traditional, single-dimensional care model centred on ‘disease treatment’ is no longer sufficient to meet the continuous, multidimensional care needs of breast cancer survivors across all stages of their life cycle. Therefore, this study will employ a narrative review methodology, taking clinical integration, professional integration, organisational integration and systemic integration as entry points. It will review the care needs of breast cancer survivors, integrated care models, the current state of service provision and practical barriers, with the aim of clarifying the current status and challenges of integrated care for breast cancer survivors and proposing targeted recommendations for improvement. This is intended to provide a reference for the development of a continuous, coordinated and comprehensive integrated care model for breast cancer survivors.
文章引用：李芳宇, 李金秀, 龙艳梅, 邓力邦, 黄心怡. 乳腺癌幸存者整合照护现状及服务困境的研究进展[J]. 护理学, 2026, 15(5): 145-154. https://doi.org/10.12677/ns.2026.155154

参考文献

[1] 李坤艳, 李璐璐, 董涧桥, 等. 乳腺癌长期幸存者生活质量的影响因素分析[J]. 河北医药, 2024, 46(1): 137-142.
[2] Bray, F., Laversanne, M., Sung, H., Ferlay, J., Siegel, R.L., Soerjomataram, I., et al. (2024) Global Cancer Statistics 2022: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA: A Cancer Journal for Clinicians, 74, 229-263. [Google Scholar] [CrossRef] [PubMed]
[3] 高乔乔, 刘东玲, 朱婷婷, 等. 社会限制对乳腺癌患者癌症适应影响的研究进展[J]. 现代临床护理, 2020, 19(10): 65-69.
[4] Han, B., Zheng, R., Zeng, H., Wang, S., Sun, K., Chen, R., et al. (2024) Cancer Incidence and Mortality in China, 2022. Journal of the National Cancer Center, 4, 47-53. [Google Scholar] [CrossRef] [PubMed]
[5] 本刊编辑部. 世界卫生组织将癌症确定为可控慢性病[J]. 中华放射肿瘤学杂志, 2007, 16(4): 268.
[6] 谢娜, 李丽, 贾杰. 不同初始肿胀部位乳腺癌相关淋巴水肿的特异性危险因素[J]. 中国康复理论与实践, 2025, 31(10): 1234-1240.
[7] 金藤, 曹磊, 王玉秀. 基于Logistic回归和决策树法预测乳腺癌术后疼痛综合征的发生风险[J]. 全科护理, 2025, 23(11): 2012-2016.
[8] 吕芳萍, 张雪雁. 乳腺癌术后患者体像水平、医疗社会支持与生活质量的相关性分析[J]. 妇儿健康导刊, 2025, 4(12): 96-100.
[9] Yao, Z., Zhao, B., Yang, X., Lei, S., Jiang, Y. and Liu, K. (2021) Relationships of Sleep Disturbance, Intestinal Microbiota, and Postoperative Pain in Breast Cancer Patients: A Prospective Observational Study. Sleep and Breathing, 25, 1655-1664. [Google Scholar] [CrossRef] [PubMed]
[10] 向玉云. 乳腺癌患者治疗期认知障碍发展轨迹及其适应方式的纵向研究[D]: [硕士学位论文]. 成都: 电子科技大学, 2023.
[11] 王芹, 吴秋盈, 王琳, 等. 基于PERMA模式的护理对乳腺癌患者干预效果的Meta分析[J]. 护理管理杂志, 2024, 24(8): 705-709.
[12] 李霞, 苏家怡, 张华. 癌症患者社会疏离评估工具的研究进展[J]. 检验医学与临床, 2025, 22(17): 2444-2448.
[13] 顾毓涵, 刘悦, 马幼蔓, 等. 年轻乳腺癌患者社会角色失调及其原因的质性研究[J]. 军事护理, 2025, 42(6): 36-39.
[14] 邹杨, 童冬彤, 杨文娟, 等. 乳腺癌患者健康信息需求研究的范围综述[J]. 中华护理教育, 2024, 21(5): 627-633.
[15] 蒋璐璐, 王喜益, 徐洁慧, 等. 智能交互式护理信息支持系统的构建及在乳腺癌患者中的应用研究[J]. 中华护理杂志, 2023, 58(6): 654-661.
[16] Rowland, J.H., Kent, E.E., Forsythe, L.P., Loge, J.H., Hjorth, L., Glaser, A., et al. (2013) Cancer Survivorship Research in Europe and the United States: Where Have We Been, Where Are We Going, and What Can We Learn from Each Other? Cancer, 119, 2094-2108. [Google Scholar] [CrossRef] [PubMed]
[17] Valentijn, P.P., Schepman, S.M., Opheij, W. and Bruijnzeels, M.A. (2013) Understanding Integrated Care: A Comprehensive Conceptual Framework Based on the Integrative Functions of Primary Care. International Journal of Integrated Care, 13, e010. [Google Scholar] [CrossRef] [PubMed]
[18] 夏艳玲, 钟雨珊. 美国pace整合型照护模式的特征及借鉴[J]. 卫生经济研究, 2019, 36(4): 55-58.
[19] Goodwin, N. (2016) Understanding Integrated Care. International Journal of Integrated Care, 16, Article 6. [Google Scholar] [CrossRef] [PubMed]
[20] Valentijn, P.P., Vrijhoef, H.J.M., Ruwaard, D., Boesveld, I., Arends, R.Y. and Bruijnzeels, M.A. (2015) Towards an International Taxonomy of Integrated Primary Care: A Delphi Consensus Approach. BMC Family Practice, 16, Article No. 64. [Google Scholar] [CrossRef] [PubMed]
[21] 代佳琪, 孙柳, 赵媛媛, 等. 超大城市社区居家整合照护服务模式要素组合研究[J]. 中国护理管理, 2025, 25(10): 1556-1562.
[22] 马天琳, 赵君, 陈永超, 等. 基于彩虹模型的整合型孕产期健康服务体系建设研究——以重庆市合川区为例[J]. 中国卫生政策研究, 2019, 12(5): 69-75.
[23] 田雨同, 张艳, 程青云, 等. 国外整合照护模式研究进展[J]. 护理研究, 2022, 36(12): 2165-2169.
[24] 覃美华, 邓玉燕, 周燕燕, 等. 乳腺癌幸存者社会疏离与未满足需求的相关性分析[J]. 心理月刊, 2024, 19(15): 27-30.
[25] Fan, R., Wang, L., Bu, X., Wang, W. and Zhu, J. (2023) Unmet Supportive Care Needs of Breast Cancer Survivors: A Systematic Scoping Review. BMC Cancer, 23, Article No. 587. [Google Scholar] [CrossRef] [PubMed]
[26] 赵苗苗, 高月霞, 徐燕飞, 等. 癌症生存者整合型照护模式的概念框架、特征及对我国的启示[J]. 中国全科医学, 2024, 27(23): 2813-2821.
[27] 阮君怡, 刘城, 况艺, 等. 年轻女性乳腺癌患者经济毒性应对困境的质性研究[J]. 护士进修杂志, 2024, 39(19): 2036-2040, 2054.
[28] 唐尧. 女性乳腺癌术后化疗患者配偶需求现状及影响因素分析[D]: [硕士学位论文]. 荆州: 长江大学, 2023.
[29] Khajoei, R., Ilkhani, M., Azadeh, P., Zohari Anboohi, S. and Heshmati Nabavi, F. (2023) Breast Cancer Survivors-Supportive Care Needs: Systematic Review. BMJ Supportive & Palliative Care, 13, 143-153. [Google Scholar] [CrossRef] [PubMed]
[30] 夏候欣琴. 乳腺癌幸存者未满足需求潜在类别及心理体验的研究[D]: [硕士学位论文]. 沈阳: 辽宁中医药大学, 2025.
[31] Elsous, A., Radwan, M., Najjar, S., Masad, A. and Abu Rayya, M. (2023) Unmet Needs and Health-Related Quality of Life of Breast Cancer Survivors: Survey from Gaza Strip, Palestine. Acta Oncologica, 62, 194-209. [Google Scholar] [CrossRef] [PubMed]
[32] Chae, B.J., Lee, J., Lee, S.K., Shin, H., Jung, S., Lee, J.W., et al. (2019) Unmet Needs and Related Factors of Korean Breast Cancer Survivors: A Multicenter, Cross-Sectional Study. BMC Cancer, 19, Article No. 839. [Google Scholar] [CrossRef] [PubMed]
[33] 国家卫生健康委员会. 全国护理事业发展规划(2021-2025年) [J]. 中国护理管理, 2022, 22(6): 801-804.
[34] 成彗芳, 黄远思, 徐雯菁, 等. 乳腺癌生存者支持性照护需求体验的质性研究[J]. 当代护士(中旬刊), 2025, 32(12): 99-105.
[35] 蔡英杰, 史铁英, 李艳娇, 等. 乳腺癌患者支持性照顾需求与生活质量的纵向研究[J]. 中国护理管理, 2018, 18(1): 134-139.
[36] 张曦, 杜雪, 王荣, 等. 乳腺癌术后患者支持性照护需求的纵向研究[J]. 护理学杂志, 2020, 35(20): 1-5, 13.
[37] 赵映. 乳腺癌化疗患者支持性照顾需求的发展轨迹及影响因素的纵向研究[D]: [硕士学位论文]. 十堰: 湖北医药学院, 2025.
[38] Singh, A., Jain, A.G., Hamilton, B.K. and Adjei, A. (2025) Care Models for Cancer Survivors. Annual Review of Medicine, 76, 225-241. [Google Scholar] [CrossRef] [PubMed]
[39] Jefford, M., Howell, D., Li, Q., Lisy, K., Maher, J., Alfano, C.M., et al. (2022) Improved Models of Care for Cancer Survivors. The Lancet, 399, 1551-1560. [Google Scholar] [CrossRef] [PubMed]
[40] Ke, Y., Fok, R.W.Y., Soong, Y.L., Loh, K.W., Farid, M., Low, L.L., et al. (2022) Implementing a Community-Based Shared Care Breast Cancer Survivorship Model in Singapore: A Qualitative Study among Primary Care Practitioners. BMC Primary Care, 23, Article No. 73. [Google Scholar] [CrossRef] [PubMed]
[41] Bhardwaj, P.V., Mason, H., Kaufman, S.A., Visintainer, P. and Makari-Judson, G. (2023) Outcomes of a Multidisciplinary Team in the Management of Patients with Early-Stage Breast Cancer Undergoing Neoadjuvant Chemotherapy at a Community Cancer Center. Current Oncology, 30, 4861-4870. [Google Scholar] [CrossRef] [PubMed]
[42] Nie, L. and Yan, Q. (2018) Progress in Research on the Application of Nursing Models for Breast Cancer Patients during the Perioperative Period. Frontiers of Nursing, 5, 83-90. [Google Scholar] [CrossRef] 
[43] Dai, Q., Liu, X., Xu, X., Fu, Y., She, Z., Huang, Y., et al. (2024) Development of a Supportive Care Framework for Breast Cancer Survivor's Unmet Needs: A Modified Delphi Study. Journal of Clinical Nursing, 33, 1376-1386. [Google Scholar] [CrossRef] [PubMed]
[44] 余之刚, 郑超. 乳腺癌多学科诊疗的现状、挑战与创新模式[J]. 山东大学学报(医学版), 2025, 63(1): 1-9.
[45] 赋能专科建设-共创健康中国多学科专家委员会, 中国抗癌协会乳腺癌专业委员会. 乳腺癌多学科诊疗标准与规范(2023年版) [J]. 中国癌症杂志, 2023, 33(12): 1188-1203.
[46] 周王青, 刘言, 刘力硕, 等. 综合护理彩虹模型的研究进展及启示[J]. 中华护理杂志, 2024, 59(4): 496-501.
[47] Gidlow, C.J., Sams, L., Buckless, K., Ellis, N.J., Duffy, H.C., Lambley-Burke, R., et al. (2024) “We Have to Change Our Mindsets”: A Qualitative Study of Barriers and Facilitators in Research Collaboration across Integrated Care System Organisations. BMC Health Services Research, 24, Article No. 264. [Google Scholar] [CrossRef] [PubMed]
[48] Dixit, N., Rodriguez, G., Sarkar, U., Burke, N., Trejo, E., Devore, D.J., et al. (2023) Identifying the Needs of Primary Care Providers Caring for Breast and Colon Cancer Survivors in the Safety-Net: A Qualitative Study. Journal of Cancer Education, 38, 845-853. [Google Scholar] [CrossRef] [PubMed]
[49] Gans, E.A., De Ruijter, U., Van der Heide, A., Van Munster, B. and De Groot, J. (2023) Closing the Gap: Multidisciplinary Coordination of a Care Plan for Patients with Multimorbidity. International Journal of Integrated Care, 23, Article 55. [Google Scholar] [CrossRef] 
[50] Jiang, C., Yabroff, R., Deng, L., Wang, Q., Perimbeti, S., Nipp, R.D., et al. (2023) Beyond Transportation: Financial Hardship, Food Insecurity, and Care Access Barriers among US Cancer Survivors with Transportation Barriers to Care. Journal of Clinical Oncology, 41, 6534-6534. [Google Scholar] [CrossRef] 
[51] Slaghmuylder, Y., Lauwerier, E. and Pype, P. (2023) Stakeholders’ Involvement in the Development and Planning of an Intervention Aimed at Integrated Care for Breast Cancer Survivors with Pain Complaints: Practical Insights and Challenges. International Journal of Integrated Care, 23, Article 126. [Google Scholar] [CrossRef] 
[52] Vuksanovic, D., Sanmugarajah, J., Lunn, D., Sawhney, R., Eu, K. and Liang, R. (2021) Unmet Needs in Breast Cancer Survivors Are Common, and Multidisciplinary Care Is Underutilised: The Survivorship Needs Assessment Project. Breast Cancer, 28, 289-297. [Google Scholar] [CrossRef] [PubMed]
[53] Franzoi, M.A., Janni, W., Erdmann-Sager, J., Kline-Quiroz, C., Schäffler, H., Pfister, K., et al. (2025) Long-Term Follow-Up Care after Treatment for Primary Breast Cancer: Strategies and Considerations. American Society of Clinical Oncology Educational Book, 45, e473472. [Google Scholar] [CrossRef] [PubMed]
[54] 贾杰. 乳腺癌患者康复的多维度关注策略[J]. 中国康复医学杂志, 2025, 40(1): 5-7.
[55] Russell, L., McIntosh, R., Martin, C., et al. (2023) Implementation of a Referral Pathway for Cancer Survivors to Access Allied Health Services in the Community. [Google Scholar] [CrossRef] 
[56] Dean, L.T., Ransome, Y., Frasso-Jaramillo, L., Moss, S.L., Zhang, Y., Ashing, K., et al. (2019) Drivers of Cost Differences between US Breast Cancer Survivors with or without Lymphedema. Journal of Cancer Survivorship, 13, 804-814. [Google Scholar] [CrossRef] [PubMed]
[57] Collaço, N., Lippiett, K.A., Wright, D., Brodie, H., Winter, J., Richardson, A., et al. (2024) Barriers and Facilitators to Integrated Cancer Care between Primary and Secondary Care: A Scoping Review. Supportive Care in Cancer, 32, Article No. 120. [Google Scholar] [CrossRef] [PubMed]
[58] Jackson, E.B., Simmons, C.E. and Chia, S.K. (2023) Current Challenges and Disparities in the Delivery of Equitable Breast Cancer Care in Canada. Current Oncology, 30, 7263-7274. [Google Scholar] [CrossRef] [PubMed]
[59] Stolarchuk, C., Anshu,, Kumar, P., Lionis, C., Anastasaki, M., Conde, M.G., et al. (2025) Optimizing Healthcare Delivery: Strategies for Workforce Retention and Resource Allocation. Journal of Surgical Specialties and Rural Practice, 6, 3-8. [Google Scholar] [CrossRef] 
[60] Pimentel-Parra, G.A., García-Vivar, C., Escalada-Hernández, P., San Martín-Rodríguez, L. and Soto-Ruiz, N. (2025) Systematic Review of Clinical Practice Guidelines for Long-Term Breast Cancer Survivorship: Assessment of Quality and Evidence-Based Recommendations. British Journal of Cancer, 133, 178-193. [Google Scholar] [CrossRef] [PubMed]
[61] 张惠婷, 张晶晶, 吴晓丹, 等. 乳腺癌患者个案管理模式的探索[J]. 护理学杂志, 2017, 32(14): 19-21.
[62] 王雅琴, 秦芹, 廖佳, 等. 个案管理师参与的多学科团队管理模式在肺癌患者围手术期的应用研究[J]. 中华胸部外科电子杂志, 2020, 7(2): 104-108.
[63] Coombs, L., Noonan, K., Diane Barber, F., Mackey, H., Peterson, M., Turner, T., et al. (2020) Oncology Nurse Practitioner Competencies: Defining Best Practices in the Oncology Setting. Clinical Journal of Oncology Nursing, 24, 296-304. [Google Scholar] [CrossRef] [PubMed]
[64] 杨冰香, 刘烁, 王金娜, 等. 模拟强化医学跨专业教育的研究进展[J]. 中华护理教育, 2020, 17(9): 799-802.
[65] Ke, Y., Tan, Y.Y., Neo, P.S.H., Yang, G.M., Loh, K.W., Ho, S., et al. (2023) Implementing an Inclusive, Multidisciplinary Supportive Care Model to Provide Integrated Care to Breast and Gynaecological Cancer Survivors: A Case Study at an Asian Ambulatory Cancer Centre. International Journal of Integrated Care, 23, Article 14. [Google Scholar] [CrossRef] [PubMed]
[66] 周倩, 倪洁, 何文翀, 等. 基层医疗卫生机构服务能力评价指标体系研究[J]. 中国农村卫生事业管理, 2022, 42(11): 796-800.
[67] Feng, Z., Lin, Y., Wu, B., Zhuang, X. and Glinskaya, E. (2023) China’s Ambitious Policy Experiment with Social Long-Term Care Insurance: Promises, Challenges, and Prospects. Journal of Aging & Social Policy, 35, 705-721. [Google Scholar] [CrossRef] [PubMed]

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