大肠肿瘤伺机性筛查——从循证医学到价值医学的转变

目的从医疗模式转变的高度,分析国内大肠肿瘤早期诊断、筛查的现状以及与世界发达国家的差异,进一步论述大肠肿瘤伺机性筛查的必要性和可行性。方法收集近35年来我国关于大肠肿瘤早期诊断、筛查的文献以及近年国外大肠肿瘤筛查指南,并进行比较分析。结果 1975～1990年、1991～2000年、2001～2010年各阶段我国关于大肠肿瘤、早期诊断、筛查的文献呈明显上升趋势,且现阶段我国的大肠肿瘤早期诊断及筛查方法学研究及进展与国外基本同步;包括美国在内的部分发达国家也提出伺机性筛查大肠肿瘤的模式。结论伺机性筛查模式适合我国现行医疗制度特点和国情,也是＂价值医学＂模式的具体体现,因而更注重医疗行为对公众个体健康的价值。     

大肠癌筛查方法与效果评价

大肠癌是常见的恶性肿瘤之一。早期大肠癌预后较好,但常因为无症状或症状不典型而被忽视和延误。因此在无症状人群中筛查大肠癌,达到早发现、早诊断、早治疗,是大肠癌的重要防治策略之一。此文对目前常用的大肠癌筛查方法及其效果作一综述。     

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。     

粪便脱落细胞及其标志物检测筛查大肠癌的研究现状

近年来大肠癌发病率呈逐年上升趋势,早期大肠癌常无临床症状,需通过筛查才能发现。目前大肠癌筛查的常用方法是粪隐血试验,但它存在假阴性和假阳性过高的局限性。为了弥补其不足,人们尝试进行粪便脱落细胞及其相关标志物的检测以探讨大肠癌早期诊断的新方法,在大肠癌筛查上具有潜在的应用前景,本文对近年有关研究进展进行系统回顾。     

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].     

内镜筛查及切除息肉病理检查在早期大肠癌诊断中的意义

为探讨临床内镜筛查及切除息肉病理检查在早期大肠癌诊断中的价值，总结分析了北医大三院１９７８年至１９９６年９月所有大肠镜检查的资料。１８年间行大肠镜检查１８１２３例、内镜下息肉切除２３４５例，共发现早期大肠癌８０例、８６个癌灶，占同期发现大肠癌总数的１５．１％（８６／５６９）。早期大肠癌的诊断率呈上升趋势，特别是１９８７年开展临床内镜筛查以来升高尤为显著。相关分析显示早期大肠癌的诊断率与内镜检查特别是内镜下息肉切除后的病理检查密切相关，提示该两项方法为诊断早期大肠癌的有效方法。     

中国自然人群筛查与伺机性检测策略预防幽门螺杆菌相关疾病的卫生经济学评价

目的:对 H.pylori自然人群筛查和伺机性检测策略用于预防 H.pylori相关疾病进行卫生经济学评价。 方法:建立 H.pylori感染、非溃疡性消化不良、消化性溃疡(PU)、胃癌等状态的马尔可夫模型,模拟计算在我国10万自然人群中实施自然人群筛查、伺机性检测和无干预...     

关注克罗恩病的早期发现和早期诊断

克罗恩病(CD)是一种慢性、进展性、破坏性肠道炎症性疾病,常伴有肠管和肠功能损害。CD发病早期缺乏特异的临床表现,确诊时30%~50%的患者已发生各种并发症,难以治愈。高危人群的伺机性筛查是CD早发现(CD前期)和早诊断(无并发症的CD)的重要策略。结肠镜检查和多种血清、粪便标记物筛查可能成为CD早诊方法。CD的早期治疗有可能改变其自然病程。     

结直肠癌筛查、监测和化学治疗进展

结直肠癌是常见的恶性肿瘤。近年来,包括我国在内的一些亚洲国家,其发病率逐年升高。鉴于结直肠癌是能早期诊断和预防的少数肿瘤之一,其筛查和监测受到许多国家胃肠病学专家的关注。本义摘录第六屑上海困际胃肠病学会议中欧美和亚太地区专家对结直肠癌防治的专题报告,着重介绍结直肠癌筛查和监测以及化学预防的一些推荐和建议。     

医院就诊人群与普查人群中大肠癌患者临床资料的比较

背景:在我国有无必要开展大肠癌普查仍存在一定争议。目的:比较、分析医院就诊人群与普查人群中大肠癌患者临床资料的异同,探讨普查在大肠癌早期诊断中的作用。方法:就诊组:由协作组各成员医院按统一设计的调查表,前瞻性地登记2002年4月1日～2003年3月31日到医院就诊,并接受结肠镜检查的大肠癌患者的全部临床资料。普查组:采用“序贯粪便隐血筛检技术”,于2001年3～6月对北京地区约2万名35岁以上的自然人群进行大肠癌普查。两组大肠癌患者的诊断均经术后病理检查证实。结果:就诊组和普查组患者中,≥50岁者分别占81.9%和83.3%。就诊组DukesA、B期患者占41.1%,普查组占91.7%(P<0.001)。普查人群中存在大肠癌高危因素者的大肠癌检出率为0.28%,无高危因素者的检出率为0.05%(P<0.001)。就诊组中,内镜表现为隆起型病变者44.7%是DukesA、B期患者,溃疡型病变者仅10.0%是DukesA、B期患者(P<0.001);DukesA、B期患者的粪便隐血试验阳性率为78.5%,C、D期患者为81.9%(P>0.05),提示粪便隐血试验阳性率与大肠癌分期无关;DukesC、D期患者的血清CEA阳性率显著高于A、B期患者(P=0.019);高、中分化癌中DukesA、B期患者占51.8%,低分化癌中DukesA、B期患者仅占26.5%(P<0.001)。结论:近年北京地区的大肠癌发病率较以前明显上升     

Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology

In the United States, colorectal cancer (CRC) is the third most common cancer diagnosed among men and women and the second leading cause of death from cancer. CRC largely can be prevented by the detection and removal of adenomatous polyps, and survival is significantly better when CRC is diagnosed while still localized. In 2006 to 2007, the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology came together to develop consensus guidelines for the detection of adenomatous polyps and CRC in asymptomatic average-risk adults. In this update of each organization's guidelines, screening tests are grouped into those that primarily detect cancer early and those that can detect cancer early and also can detect adenomatous polyps, thus providing a greater potential for prevention through polypectomy. When possible, clinicians should make patients aware of the full range of screening options, but at a minimum they should be prepared to offer patients a choice between a screening test that primarily is effective at early cancer detection and a screening test that is effective at both early cancer detection and cancer prevention through the detection and removal of polyps. It is the strong opinion of these 3 organizations that colon cancer prevention should be the primary goal of screening.     

结直肠癌筛查及其进展

结直肠癌(CRC)是最常见的恶性肿瘤之一,近年来我国CRC发病率总体呈现上升趋势,在消化系统恶性肿瘤中居第二位。CRC筛查可显著降低其发病率和死亡率,筛查方法多样,目前以免疫化学法粪便隐血试验(FIT)和结肠镜检查为基础的两步法筛查方案为多个国家的权威指南或共识所推荐,其他筛查方法可作为个体化的选择和补充。对于结直肠息肉超过10枚同时有CRC个人史或家族史,或结直肠息肉超过20枚的极高危人群,应行多基因种系突变检测。     

Current and future molecular diagnostics in colorectal cancer and colorectal adenoma

Colorectal cancer(CRC)is one of the most prevalent cancers in developed countries.On the other hand,CRC is also one of the most curable cancers if it is detected in early stages through regular colonoscopy or sigmoidoscopy.Since CRC develops slowly from precancerous lesions,early detection can reduce both the incidence and mortality of the disease.Fecal occult blood test is a widely used non-invasive screening tool for CRC.Although fecal occult blood test is simple and cost-effective in screening CRC,there is room for improvement in terms of the accuracy of the test.Genetic dysregulations have been found to play an important role in CRC development.With better understanding of the molecular basis of CRC,there is a growing expectation on the development of diagnostic tests based on more sensitive and specific molecular markers and those tests may provide a breakthrough to the limitations of current screening tests for CRC.In this review,the molecular basis of CRC development,the characteristics and applications of different non-invasive molecular biomarkers,as well as the technologies available for the detection were discussed.This review intended to provide a summary on the current and future molecular diagnostics in CRC and its pre-malignant state,colorectal adenoma.     

Colonography by CT, MRI and PET/CT combined with conventional colonoscopy in colorectal cancer screening and staging

Colorectal cancer （CRC） remains a leading cancer killer worldwide. But the disease is both curable and preventable at an early stage. Regular CRC cancer screening has been shown to reduce the risk of dying from CRC. However, the importance of large-scale screening is only now starting to be appreciated. This article reviews a variety of imaging procedures available for detecting ulcerative colitis （UC） and Crohn＇s disease （CD）, polyps and CRC in their early stage and also presents details on various screening options. Detecting, staging and re-staging of patients with CRC also require multimodality, multistep imaging approaches. Staging and re-staging with conventional colonoscopy （CC）, computer tomography colonography （CTC）, magnetic resonance colonography （MRC） and positron emission tomography/computer tomography colonography （PET/CTC） are of paramount importance in determining the most appropriate therapeutic method and in predicting the risk of tumor recurrence and overall prognosis. The advantages and limitations of these modalities are also discussed.     

国内医务人员大肠癌筛查认识现状分析及建议

目的了解我国医务人员对大肠癌筛查的认识现状,分析影响筛查的因素并提出建议。方法随机对300名来自不同地方、不同等级医疗机构的医务人员进行问卷调查并分析结果。结果147名医务人员填写调查表,应答率49.00%;55%～80%的被调查者不了解普通人群大肠癌筛查方式、起始年龄及频率;大肠肿瘤筛查的了解程度与被调查医务人员的专业、学历、工作年限、医院等级无明显关系;76.87%的被调查者推荐高危人群定期行大肠癌筛查并能指出正确的筛查方法。结论我国医务人员对大肠癌筛查的相关知识不甚清楚且重视程度不够;对高危人群大肠癌筛查有一定认识但对普通人群筛查知识了解较少。     

Viewpoints of the target population regarding barriers and facilitators of colorectal cancer screening in the Czech Republic

BACKGROUND Public awareness of colorectal cancer(CRC) and uptake of CRC screening remain challenges. The viewpoints of the target population(asymptomatic individuals older than 50) regarding CRC screening information sources and the reasons for and against participation in CRC screening are not well known in the Czech Republic. This study aimed to acquire independent opinions from the target population independently on the health system.AIM To investigate the viewpoints of the target population regarding the source of information for and barriers and facilitators of CRC screening.METHODS A survey among relatives(aged 50 and older) of university students was conducted. Participants answered a questionnaire about sources of awareness regarding CRC screening, reasons for and against participation, and suggestions for improvements in CRC screening. The effect of certain variables on participation in CRC screening was analyzed.RESULTS Of 498 participants, 478(96%) respondents had some information about CRC screening and 375(75.3%) had participated in a CRC screening test. General practitioners(GPs)(n = 319, 64.1%) and traditional media(n = 166, 33.3%) were the most common information sources regarding CRC screening. A lack of interest or time and a fear of colonoscopy or positive results were reported as reasons for non-participation. Individuals aged > 60 years [adjusted odds ratio(aOR) = 2.30, 95% confidence interval(CI)(1.42-3.71), P = 0.001], females(aOR =1.95, 95%CI(1.26-3.01) P = 0.003), and relatives of CRC patients(aOR = 4.17,95%CI(1.82-9.58) P = 0.001) were more likely to participate in screening.Information regarding screening provided by physicians-GPs:(aOR = 8.11,95%CI(4.90-13.41), P < 0.001) and other specialists(aOR = 4.19, 95%CI(1.87-9.38),P = 0.001) increased participation in screening. Respondents suggested that providing better explanations regarding screening procedures and equipment for stool capturing could improve CRC screening uptake.CONCLUSION GPs and other specialists play crucial roles in the successful uptake of CRC screening. Reduction of the fear of colonoscopy and simple equipment for stool sampling might assist in improving the uptake of CRC screening.