国内外大肠癌筛查回顾与现状—推荐“伺机性筛查”模式

本文简要回顾国内外大肠肿瘤筛查的现状以及与世界发达国家的差异;根据近年来我国大肠肿瘤筛查的实践与国外大肠肿瘤筛查指南的比较,分析我国开展大肠肿瘤伺机性筛查的必要性和可行性。基于我国现行医疗制度和国家经济状况,推荐伺机性筛查大肠肿瘤。     

开展大肠肿瘤“伺机性筛查”,提高早诊早治水平

大肠癌在中国呈上升趋势,筛查是早期发现、早期诊断的最佳手段。粪隐血试验(FOBT)以及肠镜检查是最有效的筛查方法。"伺机性筛查"(一种新的、基于临床的筛查模式)符合现阶段我国国情和政策,有必要制定我国大肠癌"伺机性筛查"的指导方案(或共识意见)。此外,应提高内镜下早期发现、早期诊断大肠癌的技术及水平。     

大肠肿瘤伺机性筛查的临床应用探讨

目前国际上大肠肿瘤的筛查有两种模式:自然人群筛查和伺机性筛查[1].自然人群筛查也称无症状人群筛查.它是通过标准化方法,进行以人群为基础的筛查.多数是由国家相关部门或组织出面,以各种手段促使符合筛查条件的全部人群(或社区、单位),在规定的、较短时间内参与筛查.这种筛查的目的不单纯是检出早期癌,提高治疗效果,更主要的是通过筛查发现痛前疾病,经过适当的干预,降低人群的发病率,起到预防大肠癌发生的作用."伺机性筛查"也称机会性筛查或个体筛查或个案筛查,是一种临床筛查、面对面的检查,可以是受检者主动找医生,也可以是医生根据受检者的危险水平决定筛查.这种筛查所针对的是个体,其目的主要在于早期检出大肠肿瘤,提高治疗效果[2].     

大肠肿瘤伺机性筛查的临床应用探讨

目前国际上大肠肿瘤的筛查有两种模式:自然人群筛查和伺机性筛查[1].自然人群筛查也称无症状人群筛查.它是通过标准化方法,进行以人群为基础的筛查.多数是由国家相关部门或组织出面,以各种手段促使符合筛查条件的全部人群(或社区、单位),在规定的、较短时间内参与筛查.这种筛查的目的不单纯是检出早期癌,提高治疗效果,更主要的是通过筛查发现痛前疾病,经过适当的干预,降低人群的发病率,起到预防大肠癌发生的作用."伺机性筛查"也称机会性筛查或个体筛查或个案筛查,是一种临床筛查、面对面的检查,可以是受检者主动找医生,也可以是医生根据受检者的危险水平决定筛查.这种筛查所针对的是个体,其目的主要在于早期检出大肠肿瘤,提高治疗效果[2].     

大肠肿瘤伺机性筛查的临床应用探讨

目前国际上大肠肿瘤的筛查有两种模式:自然人群筛查和伺机性筛查[1].自然人群筛查也称无症状人群筛查.它是通过标准化方法,进行以人群为基础的筛查.多数是由国家相关部门或组织出面,以各种手段促使符合筛查条件的全部人群(或社区、单位),在规定的、较短时间内参与筛查.这种筛查的目的不单纯是检出早期癌,提高治疗效果,更主要的是通过筛查发现痛前疾病,经过适当的干预,降低人群的发病率,起到预防大肠癌发生的作用."伺机性筛查"也称机会性筛查或个体筛查或个案筛查,是一种临床筛查、面对面的检查,可以是受检者主动找医生,也可以是医生根据受检者的危险水平决定筛查.这种筛查所针对的是个体,其目的主要在于早期检出大肠肿瘤,提高治疗效果[2].     

大肠肿瘤机会性筛查初探

目的初步探讨大肠肿瘤机会性筛查的临床应用价值。方法采用问卷调查、粪隐血试验、结肠镜检查的方法,统计分析2011年11月-2012年8月到我院消化门诊就诊患者行大肠肿瘤机会性筛查情况。结果共573例最终进入筛查,其中148例通过宣传教育后进入筛查队伍,占筛查人群的25.83%(148/573),粪隐血试验依从性为80.45%(461/573),阳性率为6.07%(28/461);结肠镜检查的依从性为90.05%(516/573)。粪隐血试验阳性人群接受结肠镜检查的依从性为92.86%(26/28);结肠镜检出大肠肿瘤共194例,检出率为37.60%(194/516),其中检出大肠癌共25例,检出率为4.84%(25/516)。结论机会性筛查人群依从性高,可以更多地检出大肠癌和癌前疾病,医师的推荐是影响筛查依从性的重要因素,开展机会性筛查是一个值得探索的适合国情的大肠肿瘤筛查模式。     

针对高危人群结直肠癌伺机性筛查的可行性分析

背景:对结直肠癌(CRC)及其癌前病变结直肠腺瘤(CRA)的筛查是降低CRC发病率的关键。伺机性筛查是适合中国国情的CRC筛查策略,针对高危人群的伺机性筛查可能进一步缩小筛查范围,节省卫生资源。目的:分析高危因素对CRC/CRA的预测价值,探讨针对高危人群的CRC伺机性筛查的可行性。方法:1 862例于2015年2月—2016年8月在中国人民解放军281医院接受结肠镜检查的门诊患者和健康体检者纳入研究。根据最新《中国早期结直肠癌及癌前病变筛查与诊治共识意见》中高危人群的判定标准,在检查前对受检者进行问卷调查,筛选出高危人群。以结肠镜检查结果为金标准,分析高危因素对CRC/CRA的预测价值。结果:共筛选出CRC/CRA高危个体468例(25.1%),高危人群的CRC检出率显著高于非高危人群(17.5%对0.9%,P=0.000)。高危因素预测CRC的敏感性为87.2%,特异性为78.2%,阳性预测值为17.5%,阴性预测值为99.1%,漏诊率为12.8%;对于CRC/CRA,相应数据分别为83.2%、87.0%、57.3%、96.1%和16.8%。高危因素对CRC和CRC/CRA的相对危险度(RR)分别为20.35和14.78。结论:针对高危人群的CRC伺机性筛查可行性较高,适合目前我国国情。     

结直肠肿瘤伺机性筛查和人群筛查的成本效果分析

背景:基于国内现实情况,伺机性筛查(OS)被推荐用于结直肠癌(CRC)的筛查和早期诊断,但国内尚缺乏比较OS和人群筛查(MS)的卫生经济学评估研究。目的:通过建立状态转移Markov模型以评估OS和MS两种模式的成本效果。方法:Markov模型设定每个模式各100 000例人进入筛查,以10年为一观察周期。筛查相关的直接费用、CRC分期相关评估费用、住院费用和相关并发症费用被包括在Markov模型中,但不包括间接费用。结直肠肿瘤筛查和管理产生的效果以增加生命年表示,成本效果分析以增量成本效果比(ICER)来评估。同时行敏感性分析。结果:OS和MS分别可预防56.79%和74.85%的CRC发生,分别增加167 185和135 254生命年。与无筛查模式相比,OS模式和MS模式增量成本分别为-1.22亿元和-0.8亿元;ICER分别为-730元和-594元。OS模式对结肠镜、粪便隐血试验、腺瘤摘除术和进展期结直肠癌的费用不敏感。结论:OS模式在结直肠肿瘤筛查和处理中更具有成本效果,应在国内临床实践中推广应用。     

智能医学在食管癌早期诊断及治疗中的应用进展

近年来,人工智能在疾病的辅助诊断、风险预测、远程医疗、智能决策等生命健康相关领域应用广泛。与传统诊疗方法相比,智能医学在食管癌等恶性肿瘤的早期筛查、智能诊断、辅助治疗等方面优势明显。食管癌是威胁我国居民健康的主要恶性消化道肿瘤之一,由于大多数食管癌患者在确诊时已为局部晚期或存在远处转移,因此,建立食管癌筛查、早诊早治和规范化诊治等智能化手段,是改善食管癌患者预后和提高患者生活质量的新策略。本文介绍智能医学在食管癌早期诊断及治疗中的应用进展。     

血浆SEPT9基因甲基化对结直肠癌诊断价值的研究进展

背景:早期筛查和诊断可有效降低结直肠癌(CRC)相关死亡率,并可提高患者总体生存率。目前的CRC早期筛查方法主要包括粪便隐血试验和结肠镜检查。粪便隐血试验敏感性低,假阳性较多,而金标准结肠镜检查为有创性检查,患者依从性较低。因此,目前临床亟需寻找有效且简便的CRC早期筛查和诊断方法。血浆SEPT9基因甲基化检测是近年来国外已开始应用的新型非创伤性CRC早期筛查和诊断方法之一,此法较为准确、简便,适合大规模筛查和早期诊断。本文就血浆SEPT9基因甲基化检测对CRC的诊断价值以及相关研究进展进行概述。     

Early diagnosis for colorectal cancer in China

AIM: To review the present studies on early diagnosis of colorectal cancer. METHODS: The detective rate for early cancer is 1.7%-26.1% based on various statistical data, with much higher detective rate in endoscopy. Since early cancer means invasion involved in the mucosa or submucosa, the diagnosis can only be made when the invasive depth is identified. Pathological tissue materials from both surgical operation or endoscopic resection are suitable for early cancer evaluation. RESULTS: Incidence of polyp malignancy is 1.4%-20.4%.The various constitutive proportion of polyps may explain the different rates.Malignant incidence is higher in adenomatous polyps, that for villous polyps can reach 21.3%-58.3%. Type II early stage of colorectal carcinoma is rarely reported in China. It is shown that majority of them were not malignant, most of type IIa being adenoma or hyperplasia, and IIb being inflammatory and IIc might be the isolated ulcers. The occurrence of malignancy of type II is far lower than that of polypoid lesion. In China, the qualitative diagnosis and classification of neoplasm generally adopted the WHO standard, including surgical excision or biopsies. There is impersonal evaluation between colorectal pre-malignancy and cancer. The former emphasizes the dysplasia of nuclei and gland, while the latter is marked with cancer invasion. Diagnosis of early stage colorectal cancer in endoscopy is made with too much caution which made the detective rate much lower. Mass screening for asymptomatic subjects and follow-up for high risk population are mainly used to find the early stage colorectal cancer in China. Fecal occult blood test is also widely made as primary screening test, galactose oxygenase test of rectal mucus (T antigen), fecal occult albumin test are also used. The detective rate of colorectal cancer is 24-36.5 per 105 mass population. CONCLUSION: Although carcinoma associated antigen in blood or stool, microsatellite DNA instability for high risk familial history, molecular biology technology for stool oncogene or antioncogene, telomerase activity and exfoliative cytological examination for tumor marker, are utilized, none of them is used in mass screening by now.     

结直肠肿瘤早诊筛查新策略：基于液体活检技术的筛查方案

结直肠肿瘤是我国最常见的恶性肿瘤之一,严重危害国民身体健康。通过简单有效的检测方法对目标人群进行筛查,早期诊断结直肠肿瘤,是降低其危害的有效策略。然而,尽管我国结直肠癌筛查取得了较大进展,但仍存在筛查方法敏感度和特异度不足,接受度和依从性较差等问题,影响了筛查效果。液体活检作为近些年来新兴的检测技术,其内涵丰富,可选择的检测靶点多,同时具有取样方便,创伤小,人群接受度高,易于推广和开展的优点,在结直肠肿瘤筛查早诊工作中具有广阔的应用前景。血液ctDNA可提供患者体内肿瘤的全景数据,在早期肿瘤患者体内含量较高,是结直肠肿瘤早诊筛查的重要靶点。     

中国结直肠癌及癌前病变内镜诊治共识（2023，广州）

结直肠癌是我国常见的恶性肿瘤之一，其发病率和死亡率均保持上升趋势，2020年中国结直肠癌新发病例55.5万例，死亡病例28.6万例，严重威胁人民生命健康。大量的研究和实践已经表明结直肠癌筛查和早诊早治可以有效降低结直肠癌的死亡率。因此，中华医学会消化内镜学分会结直肠学组牵头，联合国内消化、消化内镜以及消化病理专家共同制订了本共识，本共识主要从定义及术语、结肠镜筛查实施、结直肠癌及癌前病变早期诊断、治疗及术后注意事项和随访5个方面分别进行了阐述，以期为我国结直肠癌及癌前病变内镜诊治的规范开展提供参考，提高我国结直肠癌防治效果。     

性别与结直肠癌发病特点关系的分析

[目的]分析性别与结直肠癌临床特点的关系.[方法]收集2001-10-2011-10期间在华北地区6家医院检出结直肠癌患者资料,分析性别与发病年龄、肿瘤发生部位、腺癌分化程度的关系.[结果]2450例结直肠癌患者中男性1377例,女性1073例.男∶女为1.28∶1.00;女性发病率升高.右半结肠癌比例升高.性别与结直肠癌发生年龄、发生部位、腺癌分化程度均无明显的相关性(P＞0.05).[结论]结直肠癌发病率呈上升趋势,女性大肠癌患者比例有增加趋势.筛查是结直肠癌早诊早治的关键,筛查的起始年龄应按筛查目标确定.结直肠癌发病部位应重视右半结肠发病率升高现象,全结肠镜检查为首选.     

Population screening for colorectal carcinoma by examining feces for occult hemorrhage

Colorectal carcinoma is in the western world one of the most frequent deaths from malignant disease. A reliable way how to reduce the mortality from this disease is early diagnosis by screening in the population, the most suitable method being examination of the faeces for occult bleeding. During the last five years in the world literature results of several long-term and well elaborated studies were published focused on screening of colorectal carcinoma by detection of occult haemorrhage in the faeces. There were three American and four European papers from which ensued: 1. In the examined population in the mentioned investigations a reduction of the mortality from colorectal carcinoma was recorded as compared with a control group. 2. In the investigated population also a reduced incidence of advanced colorectal carcinoma was observed (Dukes D). 3. The optimal ratio of sensitivity and specificity was obtained by the HemeSelect test (immunodiagnosis of human haemoglobin) and the combined test (Hemoccult II Sensa + HemeSelect). Large scale examination by these tests was not verified in major population surveys so far. 4. Increasing of the sensitivity of tests using guaiacum resin by rehydration leads to a drop of the specificity of the examination and an enormous increase of coloscopic examinations and the cost of screening. 5. Part of the population with a high risk of colorectal carcinoma should be subjected to large scale examination. The problem remains its correct selection. 6. The adherence of patients to the examination differed in different trials. The increasing number and pretentiousness (dietary restrictions) of the examination reduces proportionately the percentage of cooperating subjects. Examination of the faeces for occult haemorrhage thus can be recommended for national programmes for screening of colorectal cancer.     

Screening for hereditary non-polyposis colorectal cancer: a study of 22 kindreds in The Netherlands

PURPOSE: Identification of the hereditary non-polyposis colorectal carcinoma syndrome (HNPCC) is a basis for secondary prevention. The objectives of this study are to investigate the natural history of HNPCC and to assess the effect of screening. PATIENTS AND METHODS: Screening for colorectal carcinoma was performed in 22 HNPCC families (colonoscopy or double-contrast barium enema and sigmoidoscopy). The patients were subdivided into two groups. Group A comprised patients with colorectal cancer who were referred because they were symptomatic. Group B included family members of these patients who were found to have a colorectal lesion by screening. We compared these groups with respect to the stage of tumor growth. RESULTS: Histologic examination of the tumors in Group A (87 patients) revealed Dukes A carcinomas in six patients, Dukes B carcinomas in 37, Dukes C carcinomas in 21, and Dukes D carcinomas in 10 patients (classification unknown in 13 patients). In Group B (20 patients), adenoma was found in 14 and carcinoma in six patients (Dukes A in two and Dukes B in four patients). A total of 93 patients, including those whose tumors were detected by screening, had a colorectal carcinoma. The age at diagnosis ranged from 24 to 81 years (mean age: 46 years). The location of the colonic tumors was proximal in 60 percent. Multiple primary tumors were found in 26 percent. CONCLUSION: These results suggest that screening leads to the early detection of colorectal carcinomas and adenomas in asymptomatic members of HNPCC families. Screening should be initiated at the age of 20 and continued during the life of the individual. Careful examination of the right colon is indicated because of the frequent occurrence of tumors in the proximal colon. A subtotal colectomy is indicated at the time of diagnosis of the initial colon cancer because of the risk of multiple primary tumors.     

富含半胱氨酸的酸性分泌蛋白在人大肠癌、大肠腺瘤的表达及其临床意义

[目的]探讨富含半胱氨酸的酸性分泌蛋白(SPARC)在人大肠癌、大肠腺瘤中的表达及其临床意义。[方法]采用免疫组化SABC法检测65例人大肠癌、32例人大肠腺瘤及29例正常人大肠组织中SPARC的表达。[结果]免疫组化结果显示SPARC在人大肠腺癌细胞及间质细胞均有不同程度表达。大肠癌、大肠腺瘤及正常组织三者之间比较,SPARC在组织腺管细胞中的阳性表达率差异无统计学意义(P0.05),而在间质细胞中的表达率差异显著(P0.05)。另外,在人大肠癌间质细胞中,SPARC的阳性表达率与癌组织分化程度、淋巴结转移与否呈明显相关性(P0.05),而与患者性别、年龄、肿瘤部位无关(P0.05)。[结论]SPARC有可能作为评估大肠肿瘤浸润转移及其预后的生物学指标,为进一步研究大肠肿瘤的早期筛查与诊断提供了新的思路与方法。     

国内外结直肠癌筛查的对比分析及启示

我国结直肠癌的发病率和死亡率在逐年升高,严重威胁人民群众的健康,亟待采取行之有效并且适合我国国情的结直肠癌筛查策略,从而降低结直肠癌的疾病负担。目前面临的突出问题是,我国人群结直肠癌筛查项目覆盖尚不广泛,方法并不统一,有待形成完善的国家结直肠癌筛查体系。建立筛查体系的作用在于发现癌前病变和早期病例,从而降低发病率并提高早期病例构成比,具有很重要的卫生经济学意义。本文结合国内外最新指南共识,阐述国内外结直肠癌筛查的历程和现状,比较了结直肠癌筛查常用的方法,并对我国筛查的发展提出了展望,以期未来能够建立具有我国特色的结直肠癌筛查策略。     

肝细胞癌癌前病变的诊断和治疗多学科专家共识(2020版)

肝癌目前占我国癌症死因的第二位。我国肝癌的发病特点大多遵循乙型肝炎-肝硬化-肝癌的"三步曲"模式。癌前病变的筛查在胃癌、大肠癌和宫颈癌等恶性肿瘤的诊治中已取得了显著的成果。肝硬化状态下的不典型增生结节具有较强的恶变潜能,尤其是高级别不典型增生结节癌变率极高。基于国内外在这一领域的研究成果和专家临床经验,《肝细胞癌癌前病变的诊断和治疗多学科专家共识(2020版草案)》经多学科协作对肝脏高级别不典型增生结节作为肝癌的癌前病变,从概念、筛查、诊断、治疗和随访等各方面进行了归纳和界定,旨在提出和建立肝癌癌前病变的概念和诊疗原则,为降低我国肝癌的发病率和提高肝癌的总体治疗效果作出贡献。     

肝细胞癌癌前病变的诊断和治疗多学科专家共识( 2020版)

肝癌目前占我国癌症死因的第二位。我国肝癌的发病特点大多遵循乙型肝炎-肝硬化-肝癌的“三步曲”模式。癌前病变的筛查在胃癌、大肠癌和宫颈癌等恶性肿瘤的诊治中已取得了显著的成果。肝硬化状态下的不典型增生结节具有较强的恶变潜能,尤其是高级别不典型增生结节癌变率极高。基于国内外在这一领域的研究成果和专家临床经验,《肝细胞癌癌前病变的诊断和治疗多学科专家共识(2020版)》经多学科协作对肝脏高级别不典型增生结节作为肝癌的癌前病变,从概念、筛查、诊断、治疗和随访等各方面进行了归纳和界定,旨在提出和建立肝癌癌前病变的概念和诊疗原则,为降低我国肝癌的发病率和提高肝癌的总体治疗效果作出贡献。