国内外早期结直肠癌筛查现状

<正>结直肠癌(colorectal cancer, CRC)作为当今世界的第3大癌症,已经成为严重影响人群健康的公共卫生问题之一。2019年全国癌症报告显示,CRC是我国第3大高发恶性肿瘤,占城市主要高发恶性肿瘤的第2位,农村的第5位^[1]。CRC起源于结直肠黏膜上皮,是消化道最常见的恶性肿瘤之一,其典型机制是经腺瘤性息肉逐渐演变为癌。大部分的CRC源于结肠息肉,只有20%～30%经过除此以外的途径。从腺瘤发展为癌需要5～≥20年,     

结直肠癌筛查对结直肠肿瘤早期诊断的意义

背景：我国结直肠癌（CRC）发病率和死亡率呈上升趋势,发病年龄趋于年轻化。目的：分析CRC筛查初筛阳性人群的结肠镜检查结果,探讨高危问卷联合粪便隐血试验的CRC筛查模式对于结直肠肿瘤早期诊断的意义。方法：连续纳入2013年5月—2019年10月参与上海市黄浦区社区CRC筛查,因初筛结果阳性至瑞金医院卢湾分院接受结肠镜检查的高危个体,内镜检查发现病变者取活检或摘除送病理检查。同期因排便习惯改变行结肠镜检查的患者作为对照组。分析两组结直肠肿瘤检出情况以及筛查阳性组的病变特征。结果：共1 329例初筛阳性者纳入研究,结肠镜检查病变总体检出率为63.3%,CRC、息肉和腺瘤性息肉检出率分别为2.6%(34例)、60.7%(807例)和35.2%(468例),均显著高于对照组（n=22 438）的43.6%、1.8%、41.5%和21.6%(P均<0.05)。筛查阳性组病变检出率男性显著高于女性（73.7%对54.2%, P<0.05）,且随年龄增长呈增高趋势（P<0.05）。CRC主要分布于60～79岁年龄组,无性别分布差异,病变直径均≥1 cm;发生异型增生的腺瘤直径亦多≥...     

高敏定量粪便免疫化学试验对结直肠癌和进展期腺瘤的诊断效能

目的探究高敏定量粪便免疫化学试验(hs-qFIT)对结直肠癌和进展期腺瘤的诊断效能。方法连续性纳入2020年7至12月于山东大学齐鲁医院进行结肠镜检查且亚太结直肠癌筛查评分为中危或高危的50～75岁患者。所有患者在结肠镜检查前需完成2次hs-qFIT检测。评估hs-qFIT对结直肠癌和进展期腺瘤的诊断效能, 计算受试者操作特征曲线下面积(AUC)。结果最终纳入811例患者, 其中结直肠癌20例(2.5%), 进展期腺瘤47例(5.8%), 非进展期腺瘤206例(25.4%), 非腺瘤性息肉219例(27.0%), 其他病变76例(9.4%), 无异常243例(30.0%)。当粪便血红蛋白截断值为10、30、50、75和100 ng/mL时, hs-qFIT检测阳性率分别为17.9%(145/811)、10.9%(88/811)、8.3%(67/811)、7.4%(60/811)和5.8%(47/811)。粪便血红蛋白截断值由100 ng/mL降低至10 ng/mL时, hs-qFIT诊断结直肠癌的灵敏度由90.0%上升至100.0%, 特异度由96.3%下降至84.2%, 诊断进展期腺...     

定期反馈对结直肠癌机会性筛查中 腺瘤检出率的影响

目的探索在全结肠镜检查行结直肠癌机会性筛查中实行腺瘤检出率（adenoma detection rate,ADR）定期反馈制度是否可提高内镜医师ADR。方法本研究为观察性研究,研究分为3个阶段：干预前的基线阶段（简称干预前）、定期反馈阶段（简称干预期）和干预后阶段（简称干预后）。干预前：回顾2017年6月—2018年5月在首都医科大学附属北京世纪坛医院消化内科进行结直肠癌机会性筛查的所有患者资料,计算每名内镜医师的ADR。干预期：2018年6月—2018年11月由参与反馈的内镜医师对结直肠癌机会性筛查的患者进行全结肠镜检查,每个月初计算每名内镜医师前一个月的ADR并以报告单的形式提供反馈。干预后：2018年12月—2019年1月由参与反馈的内镜医师对结直肠癌机会性筛查的患者进行全结肠镜检查,计算反馈干预停止后每名内镜医师的ADR。比较3个阶段的ADR和息肉检出率（polyp detection rate,PDR）。结果干预前、干预期和干预后分别纳入1 768例、1 308例和344例结直肠癌机会性筛查患者。共有8名内镜医师参与研究全过程。总ADR从干预前的23.70%（419/1 768）升高至干预期的33.72%（441/1 308）（χ2=37.449,P＜0.05）。干预后2个月,ADR轻度下降至33.14%（114/344）,但与干预前相比,仍然升高（χ2=13.602,P＜0.05）。总PDR从干预前的47.17%（834/1 768）提高至干预期的52.68%（689/1 308）,两者相比差异有统计学意义（χ2=9.111,P＜0.05）。停止干预后,PDR轻度上升至53.78%（185/344）,与干预前相比差异有统计学意义（χ2=5.035,P＜0.05）。结论在结直肠癌机会性筛查中,对内镜医师进行ADR的定期反馈可以提高结直肠ADR。     

结直肠癌筛查技术的研究进展

结直肠癌(CRC)是常见恶性肿瘤之一,近年来随着人们生活方式及饮食结构的改变,中国CRC的发病率逐年升高。CRC的转归和预后与肿瘤分期密切相关,大部分早期CRC患者可获得良好预后,而发生远处转移的晚期CRC患者的5年生存率仅为12%。因此开展CRC筛查,以期及早发现并治疗早期CRC和癌前病变,对提高患者的生存率及生活质量具有重要的临床价值。该文就CRC的早期筛查技术的研究进展作一综述,主要包括基于粪便的检查和内镜及影像学检查。     

粪便检查在结直肠癌筛查中的作用

结直肠癌（CRC）是消化系统常见的恶性肿瘤之一,近年来其发病率和病死率呈上升趋势.结直肠癌具有较明确的癌前病变,西方国家很早就致力于推广筛查方案,在过去的30年中其发病率和病死率明显下降.目前,结直肠癌筛查手段主要分为两大类：粪便检查和结肠结构性检查.前者包括粪便潜血、钙卫蛋白、粪便基因学及粪便MicroRNA检查等,后者包括全结肠镜、乙状结肠镜检查、钡灌肠、CT仿真结肠镜等.     

结肠镜筛查203例无症状人群结直肠癌及腺瘤检出率分析

目的了解澳门无症状人群通过肠镜筛查的结直肠癌及腺瘤检出率及其临床特征。 方法选择2012年1月至12月于我院进行肠镜检查的无症状人群203例,回顾性分析其临床特征和病理活检结果,并分析肠癌及腺瘤患者的高危因素。 结果203例受检者中检出结肠癌3例(1.48%),腺瘤70例(34.48%),其中高危腺瘤30例(14.78%)。60岁以上受检者腺瘤检出率高于50岁以下受检者(P＝0.013),有吸烟史人群高危腺瘤检出率高于无吸烟史者(P＝0.037)。 结论对无症状人群的全结肠镜筛查有助于早期发现肠癌及腺瘤。年龄大于60岁是结肠腺瘤的高危因素,吸烟史是结肠高危腺瘤的高危因素。     

机器学习算法预测模型在结直肠癌筛查中的应用进展

结直肠癌（CRC）患者约占全球所有新发肿瘤患者的10%,健康人群患CRC的风险为4%～5%,是肿瘤相关死亡的常见原因之一。目前筛查CRC的方法很多,如结肠镜、肿瘤标志物、影像学、微环境、病理学等,但是都有其不足之处。近年来随着深度学习、机器学习算法（ML）、硬件水平和数据库的提升,人工智能（AI）技术迎来第三次发展热潮,将ML与CRC的筛查方法相结合,能有效提高其敏感度及特异度,减少人工检测所带来的失误。目前研究显示,基于结肠镜检查、肿瘤标志物、影像学检查、肠道微环境、病理学检查的ML预测模型可以提高CRC筛查的准确性,减少不必要的人为错误,在提高效率的同时也减少了不必要的劳动浪费。ML有很多种预测模型,每个模型都有其自身的优势,我们要根据目标的不同特点进行合理选择,以提高CRC的筛查效果。     

免疫法粪便潜血试验在结直肠癌筛查中的价值

目的 探讨免疫法粪便潜血试验(IFOBT)在大系列健康体检人群中筛查结直肠癌及其癌前病变的临床价值.方法 对2006年7月至2007年6月间在上海交通大学医学院附属仁济医院行健康体检的5919例采用IFOBT筛查结直肠癌及其癌前病变,对阳性病例进行结直肠镜检查或x线钡剂灌肠检查,结合临床及病理资料进行分析.结果 5919例体检人群中IFOBT阳性者314例,阳性率为5.30%,其中241例(76.75%)接受了结直肠镜检查,23例(7.32%)接受了X线钡剂灌肠检查,总随访率达84.08%,失访50例.剔除失访病例后,共发现结直肠癌16例,检出率为2.73‰(16/5869),其中Dukes A期8例(50.00%),Dukes B期7例(43.75%),Dukes C期1例(6.25%),IFOBT阳性者中的结直肠癌检出率为6.06%(16/264).共发现结直肠腺瘤样息肉94例,检出率为16.01‰(94/5869),包括管状腺瘤55例(58.51%),绒毛状-管状腺瘤23例(24.47%),绒毛状腺瘤16例(17.02%),其中单发者55例(58.51%),多发者39例(41.49%);另见活动期溃疡性结肠炎6例.IFOBT阳性者中共检出116例结直肠癌或癌前病变,检出率为43.94%(116/264).结论 IFOBT适合于大系列人群结直肠癌及其癌前病变的筛查,能发现较早期结直肠癌和癌前病变,使疾病在可治愈阶段得到根治,从而有望减少结直肠癌的发病率和死亡率.     

Screening Colonoscopy for Colorectal Cancer in Asymptomatic People: A Meta-Analysis

Objective The preferred method for screening asymptomatic people for colorectal cancer (CRC) is colonoscopy, according to the new American guidelines. The aim of our study was to perform a meta-analysis of the prospective cohorts using total colonoscopy for screening this population for CRC. We looked for the diagnostic yield of the procedure as well as for its safety in a screening setting. Methods We included papers with more than 500 participants and only those reporting diagnostic yield of adenoma (and/or advanced adenoma) and CRC. Nested analysis were performed for secondary endpoints of complications and CRC stages when this information was available. All analyses were performed with StatDirect Statistical software, version 2.6.1 (). Results Our search yielded ten studies of screening colonoscopy conducted in asymptomatic people that met our inclusion criteria, with a total of 68,324 participants. Colonoscopy was complete and reached the cecum in 97% of the procedures. Colorectal cancer was found in 0.78% of the participants (95% confidence interval 0.13–2.97%). Stage I or II were found in 77% of the patients with CRC. Advanced adenoma was found in 5% of the cases (95% confidence interval 4–6%). Complications were rare and described in five cohorts. Perforation developed in 0.01% of the cases (95% confidence interval 0.006–0.02%) and bleeding in 0.05% (95% confidence interval 0.02–0.09%). Conclusions Our findings support the notion that colonoscopy is feasible and a suitable method for screening for CRC in asymptomatic people.     

自然人群序贯粪隐血试验连续性结直肠癌普查的队列研究：19年结果分析

筛查是早期发现结直肠癌（CRC）的重要手段。目的：评价自然人群序贯粪隐血试验（SFOBT）连续性CRC普查在提高早期CRC检出率、患者长期生存率和降低CRC发生率方面的作用。方法：于1987～2005年，应用SFOBT对一组基本固定的中老年人群（初次普查人群3002例）行连续性CRC普查。每1～2年接受一次普查者计入普查组，连续3年或3年以上未接受普查者计入未普查组。FOBT阳性者行结肠镜检查。于北京军区总医院行手术治疗的1033例CRC患者作为对照组。结果：19年中普查人群共发生CRC52例，总CRC发生率为90．4／10万人·年。普查组共检出CRC25例，漏诊7例，CRC检出率为57．6／10万人·年，发生率为73．8／10万人·年；未普查组发生CRC20例，发生率为141．4／10万人·年。普查组DukesA／B期患者比例（95．5％对31．2％和43．9％，P〈0．05）和5年生存率（77．8％对33．3％和39．8％，P〈0．05）显著高于未普查组和对照组。SFOBT筛查CRC的19年总敏感性为90．6％，特异性为98．0％，阳性预测值为3．2％，阴性预测值为99．99％。结论：SFOBT应用于自然人群连续性普查可提高早期CRC检出率和患者5年生存率。切除普查中发现的腺瘤可明显降低CRC发生率。该筛查方案具有较高的敏感性和特异性，但仍需高度关注其结肠镜检查的依从性.     

胆囊切除与结直肠息肉相关性的研究

背景：胆囊切除已被认为是结直肠癌的危险因素之一,但胆囊切除与结直肠息肉的关系一直未受到重视。目的：探讨胆囊切除与结直肠息肉的相关性。方法：连续收集经结肠镜排除恶性肿瘤、炎症性肠病、家族性腺瘤性息肉病等疾病的患者425例,根据既往有无胆囊切除史分为胆囊切除组（n=63）和对照组（n=362）,对两组患者结直肠息肉的发生率、内镜下息肉表现和组织学类型进行分析。结果：胆囊切除组结直肠息肉发生率高于对照组（46.0%对37.8%）,但差异无统计学意义（P=0.219）。两组患者息肉的部位和形态均无明显差异（P=0.753,P=0.127）;但胆囊切除患者腺瘤性息肉的发生危险显著高于对照组（OR=1.79,P=0.006）。亚组分析示胆囊切除史≥10年的结直肠息肉发生率与胆囊切除史〈10年无明显差异（P=0.11）。结论：胆囊切除并未增加结直肠息肉发生的危险性,但腺瘤性息肉的发生率显著增高,因此对胆囊切除患者应重视早期结直肠癌和腺瘤性息肉的筛查。     

Upper Gastrointestinal Cancer in a Population-based Screening Program with Fecal Occult Blood Test for Colorectal Cancer

Background : Screening with Hemoccult-II ® (H-II) followed by colonoscopy, when fecal occult blood is demonstrated, reduces mortality from colorectal cancer. Whether upper gastrointestinal investigation is necessary when colonoscopy does not reveal any significant colorectal lesion is doubtful, and is the subject of this study. Material : In 1985, 30,967 persons from the general population register of Funen were randomized to biennial H-II screening. A positive test was followed by colonoscopy and no attempt was made to evaluate the upper gastrointestinal tract. Based on the information from the Funen Patient Database, the National Board of Health's Register of Death Causes, the Cancer Register and the National Register of Patients, all persons with malignancy of the gastrointestinal tract were identified. Results : During 15 years and 8 screening rounds, 1,767 tests were positive; 1,536 complete colonic investigations detected colorectal cancer in 182 persons, adenoma &#83 10 mm in 440 persons, and in 879 investigations no colorectal lesion was found. Upper GI cancers were diagnosed in 209 persons within 2 years of the H-II test (199 after a negative H-II and no more than 10 persons within 2 years of a positive test). Among the 10, two were diagnosed as a consequence of symptoms at the time of screening. Conclusion : It is unjustified to perform upper gastrointestinal investigation in asymptomatic persons with a positive H-II in a Danish population screening for colorectal cancer.     

Colorectal Cancer Screening and Surveillance in the Elderly: Updates and Controversies

Colorectal cancer is common worldwide, and the elderly are disproportionately affected. Increasing age is a risk factor for the development of precancerous adenomas and colorectal cancer, thus raising the issue of screening and surveillance in older patients. Elderly patients are a diverse and heterogeneous group, and special considerations such as comorbid medical conditions, functional status and cognitive ability play a role in deciding on the utility of screening and surveillance. Colorectal cancer screening can be beneficial to patients, but at certain ages and under some circumstances the harm of screening outweighs the benefits. Increasing adverse events, poorer bowel preparation and more incomplete examinations are observed in older patients undergoing colonoscopy for diagnostic, screening and surveillance purposes. Decisions regarding screening, surveillance and treatment for colorectal cancer require a multidisciplinary approach that accounts not only for the patient’s age but also for their overall health, preferences and functional status. This review provides an update and examines the challenges surrounding colorectal cancer diagnosis, screening, and treatment in the elderly.     

T抗原检测对大肠癌病人的临床意义

目的:为评价T抗原检测对大肠癌普查的价值.方法;用半乳糖氧化酶-雪夫液(GO-S)方法,对166例不同对象的直肠粘液标本进行T抗原检测.结果:40例大肠癌组、33例大肠息肉组、18例结直肠炎组、56例对照组,T抗原的阳性率分别为85.0%、24.2%、11.1%和10.7%.前两者与对照组相比差异显著(P<0.01和P<0.05).结论:GO-S作大肠癌和息肉T抗原检测,具有较高的敏感性(85.0 %)和特异性(89.3 %),因此,可作为潜在的结直肠癌筛检应用,同时也为结直肠息肉筛检提供了一种方法.     

Screening for Colorectal Cancer in Personnel of an Academic Medical Center

The colorectal cancer (CRC) screening program in Israel offers the average-risk population fecal occult blood tests from the age of 50 years. Compliance, however, is very low, reaching only 6% of eligible persons in 2005. Our aim in this study was to describe the results of an improved CRC screening program directed at the in-house staff of Beilinson Hospital. All employees of Beilinson Hospital over age 50 years were sent a letter explaining the new CRC screening program and an accompanying questionnaire. Responders who reported a family history of CRC or related cancers or symptoms were offered colonoscopy; the remainder were offered sigmoidoscopy or, if they preferred, colonoscopy. Two hundred twenty of the 888 candidates (24.7%) completed the questionnaire, of whom 144 (16.2%) agreed to further investigation. These included 90 of 105 patients with a positive questionnaire and 20 of 115 with a negative questionnaire who underwent colonoscopy and 34 of 115 with a negative questionnaire who underwent sigmoidoscopy. The colonoscopy group included 26 of the 30 patients (86.6%) with a positive family history. Early-stage CRC was diagnosed in three patients (1.36%), all with a positive questionnaire. There were no pathologic findings on sigmoidoscopy. The sensitivity, specificity, and positive and negative predictive values of the questionnaire for identifying subjects with CRC or advanced adenoma were 100.00%, 18.86%, 2.27%, and 100.00%, respectively. In conclusion, using hospital facilities, we initiated a unique CRC screening program for employees. Our method may be applicable in other medical centers for the detection of adenomas and CRCs in the early, curative stages.     

Colorectal cancer disparities: Issues,controversies and solutions

Colorectal cancer(CRC)is the second leading cause of cancer related deaths in the United States.There are significant differences in CRC incidence and mortality by race with the highest burden occurring among blacks.The underlying factors contributing to CRC disparities are multiple and complex.Studies have suggested that a higher prevalence of putative risk factors for CRC,limited access to healthcare services,lower utilization of healthcare resources and increased biological susceptibilities contribute to this disparity by race.This article reviews the factors associated with the disproportionally higher burden of CRC among blacks;addresses the controversies regarding the age to begin CRC screening and the screening modality to use for blacks;and proffers solutions to eliminate CRC disparity by race.