各国乳腺癌筛查指南中一般风险对象筛查方案的比较

乳腺癌是全世界女性发病率最高的恶性肿瘤之一,现有证据证实可以通过有组织的人群筛查降低乳腺癌死亡率.全球多个癌症研究机构和专业组织已形成不同的乳腺癌筛查指南以规范群体筛查行为.针对一般风险对象,这些指南均推荐乳腺X射线摄影术作为筛查手段,而对于筛查间隔时间和筛查开始年龄的推荐则有所不同.关于开始筛查年龄,各个指南主要的争...     

2015版美国癌症协会乳腺癌筛查指南解读

目的 简介2015年美国癌症协会(American Cancer Society,ACS)公布的乳腺癌筛查最新指南.方法 与2003版ACS指南相比,分析2015版ACS指南的更新要点;结合其他重要的国际乳腺癌筛查指南及中国实际情况,讨论2015版ACS指南存在的不足及可借鉴之处.结果 2015版ACS指南主要更新要点在于推荐乳腺癌发病平均风险女性应从45岁起常规进行乳房摄影术筛查,并且不推荐临床乳腺检查作为任何年龄平均风险女性的乳腺癌筛查方法.由于中国和欧美女性乳腺质地、体积和经济情况的差异,ACS推荐的乳腺癌筛查方案并不完全适用于中国女性.结论 在借鉴ACS指南基础上,应针对中国女性乳房生理特点及乳腺癌流行病学特征制定适用于我国的乳腺癌筛查指南.     

中国乳腺癌筛查与早期诊断指南

中国抗癌协会乳腺癌专业委员会于2020年4月—2021年11月,采用改编《欧盟委员会乳腺癌指南》的方法,编写制定了《中国乳腺癌筛查和早期诊断指南》（后文简称指南）。指南遵循GRADE系统方法,共包括50条推荐意见和5条专家共识,涉及乳腺癌的筛查、早期诊断、复发风险基因检测以及筛查项目中的沟通和培训等专业领域。指南推荐意见的形成考虑了目前最佳循证医学证据、中国女性群体的价值观念与偏好、成本和资源配置等因素。在应用本指南推荐的筛查和诊断技术时,应结合各地实际情况。     

乳腺癌筛查的思考

乳腺癌筛查虽在西方世界获得降低死亡率的实效,但有关其利弊之争迄今未息。本文结合中国的实际,就筛查年龄段的取舍、城乡发病的考虑、筛检方法的选择,以及组织形式与筛查方案等进行了讨论,提出了增利减弊的建议。     

乳腺癌的发病趋势及筛查

近几十年来，西方发达国家的乳腺癌发病率有不同程度的上升。虽然发展中国家乳腺癌的发病率较低，但全球乳腺癌的一半病例发生在发展中国家，其中中国、印度等国占了相当大的比例。因此，了解我国乳腺癌的发病趋势并采取相应对策已刻不容缓。一、乳腺癌的发病趋势乳腺癌是西方国家最常见的恶性肿瘤。据美国癌症协会估计，1994年全美国有18．2万新发乳腺癌病人，约4．6万名病人将死于该疾病。对于年龄40岁一55岁的美国妇女，乳腺癌超过心脏病而成为第一位死因。据美国国立癌症研究所监测、流行病学和最终结果项目（SEER）的资料，美国妇女…     

《中国女性乳腺癌筛查指南》解读（精简版）

乳腺癌是中国女性最常见的恶性肿瘤，早期筛查是提高乳腺癌早诊早治最佳途径。中国女性乳腺癌发病高峰年龄与欧美国家乳腺癌发病高峰年龄明显不同，制定适合中国女性特点的群体性乳腺癌筛查指南势在必行。中国抗癌协会与国家肿瘤临床医学研究中心（天津医科大学肿瘤医院）组织专家在分析总结中国女性乳腺癌筛查数据的基础上，参考欧美及东亚等国家的最新乳腺癌筛查指南或共识，分别从筛查起始年龄、筛查方法、筛查时间间隔3个方面，针对中国女性乳腺癌一般风险人群和高危风险人群制定以人群为基础的《中国女性乳腺癌筛查指南》，本文对该指南进行解读以供乳腺癌筛查相关人士参考。      

超声检查用于亚洲女性乳腺癌筛查卫生经济学研究的系统评价

摘 要：［目的］对亚洲地区乳腺癌筛查中应用超声检查技术的卫生经济学研究进行系统评价。［方法］系统检索PubMed、Medline、Cochrane、CNKI、万方、维普（VIP）数据库,检索时限均为建库到2018年1月。由两位研究者独立筛选文献,对纳入研究的基本信息、人群项目参与率及检出率、经济学评价方法及结果等信息进行摘录和比较,采用Meta-Disc 1.4进行Meta分析。［结果］共检索获得文献197篇,最终纳入文献9篇（英文1篇,中文8篇）,发表于2011～2017年,总样本量为912 771例,筛查对象年龄≥30岁。超声检查技术确诊1例乳腺癌成本平均为271 282元,获得1个质量调整生命年成本为286.37元。在筛查效能方面,超声检查技术的敏感性为91%,特异性为100%。［结论］纳入的研究显示亚洲地区应用超声技术进行乳腺癌筛查的经济学研究仍有限,并且主要集中在中国大陆地区。不同研究在方法学及报道结果方面可比性不足,研究质量有进一步提升空间。     

乳腺癌社区筛查策略的探讨

目的探讨乳腺癌社区筛查的方法。方法对3个社区共13378人乳腺癌筛查按社区分成3组,分别采取组1：社区宣教＋医院免费体检以及推荐钼钯检查;组2：发放免费医院体检表以及推荐钼钯检查;组3：社区宣教＋推荐钼钯检查。统计各组来院检查率、钼钯摄片率、乳腺癌检出率。结果组1共发放免费体检表7973张,来院检查人数5176人,占64．92％。组2共发放免费体检表10097张,来院检查人数5267人,占52．16％。组3共发放免费体检表8013张,来院检查人数2935人,占36．63％。组1钼钯摄片数共1289人,占24．9％;组2钼钯摄片542人,占10．29％;组3钼钯摄片120人,占4．09％。3个社区实际发现乳腺癌21例,总发病率为80．51／10万。其中通过本次筛查发现13例。受筛查者到目前没有发现漏诊病例。组1诊断乳腺癌6例,组2诊断乳腺癌5例,组3诊断乳腺癌2例。结论社区宣教＋医院免费体检＋推荐钼钯检查是目前比较适合国情的乳腺癌筛查方法。     

国际乳腺癌筛查指南的争议引发的思考

2015年和2016年陆续公布的世界卫生组织国际癌症研究署(WHO-IARC)专家组对全球乳腺癌筛查提出的指导性意见,美国癌症学会(ACS)乳腺癌筛查指南更新版及美国预防服务工作组(USPSTF)最新的乳腺癌筛查指南;对乳房X线筛查的认识和建议存在较大差异.本文就国际权威机构在乳房X线筛查指南及推荐上的主要分歧进行了梳理,并分析了出现意见分歧的潜在原因;继而概括介绍了中国女性乳腺癌群体筛查的历史和现状;并进一步结合欧美国家乳房X线筛查的热点问题,对中国开展乳腺癌筛查的重点问题,如:接受筛查人群的起止年龄、筛查中采用的主要手段及筛查的间隔时间等逐一进行了解析.最终建议中国乳腺癌群体筛查方法 可按地域、医疗资源、受试者年龄进行相应调整,并提出中国乳腺癌筛查项目实施的建设性意见.     

Progress in screening for early breast cancer

Ten years have now passed since the American Cancer Society/National Cancer Institute sponsored Breast Cancer Detection Demonstration Projects (BCDDP) started to evaluate the use of mammography, physical examination, thermography, and breast self-examination in screening women for the presence of unsuspected breast cancer. Criteria have been developed to evaluate population screening as an approach to cancer control and breast cancer screening techniques. Combined physical examination and mammography have been particularly successful in detecting early breast cancer. Although the number of screening programs for breast cancer has increased in the past decade, real progress has been surprisingly slow and the issues in breast cancer screening have proved to be subtle and complex.     

Disparities in cancer screening in individuals with a family history of breast or colorectal cancer

BACKGROUND:

Understanding racial/ethnic disparities in cancer screening by family history risk could identify critical opportunities for patient and provider interventions tailored to specific racial/ethnic groups. The authors evaluated whether breast cancer (BC) and colorectal cancer (CRC) disparities varied by family history risk using a large, multiethnic population‐based survey.

METHODS:

By using the 2005 California Health Interview Survey, BC and CRC screening were evaluated separately with weighted multivariate regression analyses, and stratified by family history risk. Screening was defined for BC as mammogram within the past 2 years for women aged 40 to 64 years; for CRC, screening was defined as annual fecal occult blood test, sigmoidoscopy within the past 5 years, or colonoscopy within the past 10 years for adults aged 50 to 64 years.

RESULTS:

The authors found no significant BC screening disparities by race/ethnicity or income in the family history risk groups. Racial/ethnic disparities were more evident in CRC screening, and the Latino‐white gap widened among individuals with family history risk. Among adults with a family history for CRC, the magnitude of the Latino‐white difference in CRC screening (odds ratio [OR], 0.28; 95% confidence interval [CI], 0.11‐0.60) was more substantial than that for individuals with no family history (OR, 0.74; 95% CI, 0.59‐0.92).

CONCLUSIONS:

Knowledge of their family history widened the Latino‐white gap in CRC screening among adults. More aggressive interventions that enhance the communication between Latinos and their physicians about family history and cancer risk could reduce the substantial Latino‐white screening disparity in Latinos most susceptible to CRC. Cancer 2011;. © 2011 American Cancer Society.     

Mammography screening in the Netherlands: delay in the diagnosis of breast cancer after breast cancer screening

In a prospective study we determined the frequency and causes of delay in the diagnosis of breast cancer after suspicious screening mammography. We included all women aged 50-75 years who underwent biennial screening mammography in the southern breast cancer screening region of the Netherlands between 1 January 1996 and 1 January 2002. Clinical data, breast imaging reports, biopsy results and breast surgery reports were collected of all women with a positive screening result with a minimum of 2-year follow-up. Of 153 969 mammographic screening examinations, 1615 (1.05%) were positive screens. Breast cancer was diagnosed in 770 (47.9%) of 1607 women for whom follow-up information was available, yielding a cancer detection rate of 5.0 per 1000 women screened. Breast cancer was diagnosed within 3 months following a positive screen in 722 cases (93.8%). The diagnostic delay was 4-6, 7-12 and 13-24 months, respectively, in 11 (1.4%), 24 (3.1%) and nine (1.2%) patients. In four other patients (0.5%), breast cancer was diagnosed after a repeat positive screen, resulting in a diagnostic delay of 25-27 months. Reasons for a diagnostic delay >3 months were erroneous mammographic interpretation of suspicious lesions as benign or probably benign lesions (33 cases), benign biopsies from a malignant lesion (10), and omission to biopsy or remove a lesion that was suspicious at breast imaging (4) or core biopsy (1). We conclude that there is room for improvement in the workup of patients with a positive screening mammography, as seen from data in this screening region. To improve the workup, we suggest that other breast cancer screening programmes also identify delay in breast cancer diagnosis after a positive screen.     

Breast cancer screening uptake in women at increased risk of developing hereditary breast cancer

This multicenter study assessed breast cancer screening uptake in 461 unaffected women at increased risk of developing breast cancer on the basis of family history who approached familial cancer clinics for advice about surveillance options. At the time of attending the clinic, 89% and 90% of participants were vigilant with respect to age- and risk-specific recommendations for mammography and clinical breast examination, respectively, and 51% reported practicing breast self-examination monthly or more frequently. The degree to which health outcomes are perceived to be under one's personal control (²=–2.09, p=0.0037) and breast cancer anxiety (²=8.11,p=0.044) were both associated with monthly or more frequent breast self-examination, while there were no associations with sociodemographic characteristics. A significantly lower percentage (56%) of women aged <30 were vigilant with respect to mammography recommendations, compared to 77%, 96% and 98% of women aged 30–39, 40–49 and >50, respectively (²=37.2,p<0.0001). These relatively low rates of mammographic screening in young women may reflect concerns about increased cancer risk associated with early and repeated radiation exposure or lack of sensitivity in young women with radiographically dense breasts. If mammographic screening is ultimately shown to lower mortality in women at high risk, there will be a strong case to promote screening in young women. The need for regular mammographic screening would then need to be highlighted and reinforced amongst young women and their referring physicians. Awareness amongst general practitioners, who are largely responsible for referral to screening services, would also need to be increased.     

Polygenic susceptibility to prostate and breast cancer: implications for personalised screening

Background:

We modelled the efficiency of a personalised approach to screening for prostate and breast cancer based on age and polygenic risk-profile compared with the standard approach based on age alone.

Methods:

We compared the number of cases potentially detectable by screening in a population undergoing personalised screening with a population undergoing screening based on age alone. Polygenic disease risk was assumed to have a log-normal relative risk distribution predicted for the currently known prostate or breast cancer susceptibility variants (N=31 and N=18, respectively).

Results:

Compared with screening men based on age alone (aged 55–79: 10-year absolute risk ⩾2%), personalised screening of men age 45–79 at the same risk threshold would result in 16% fewer men being eligible for screening at a cost of 3% fewer screen-detectable cases, but with added benefit of detecting additional cases in younger men at high risk. Similarly, compared with screening women based on age alone (aged 47–79: 10-year absolute risk ⩾2.5%), personalised screening of women age 35–79 at the same risk threshold would result in 24% fewer women being eligible for screening at a cost of 14% fewer screen-detectable cases.

Conclusion:

Personalised screening approach could improve the efficiency of screening programmes. This has potential implications on informing public health policy on cancer screening.     

The American Cancer Society guidelines for breast screening with magnetic resonance imaging: an argument for genetic testing

BACKGROUND.

The American Cancer Society (ACS) guidelines for screening with breast magnetic resonance imaging (MRI) recommend MRI for women who have a lifetime risk ≥20% of developing breast cancer. Genetic testing for breast cancer gene (BRCA) mutations is offered to women who have a risk ≥10% of carrying a mutation. The objectives of the current study were 1) to identify the number of women in a breast cancer screening population who had ≥20% lifetime breast cancer risk and, thus, were candidates for screening MRI; and 2) to determine the number of women who had ≥10% risk of BRCA mutation yet had <20% lifetime risk of breast cancer and, thus, may not have been identified as candidates for MRI screening.

METHODS.

From 2003 to 2005, women who underwent screening mammography completed a self‐administered questionnaire regarding breast cancer risk factors. For each patient, the lifetime breast cancer risk and the risk of BRCA mutation was determined by using the computerized BRCAPRO breast cancer risk‐assessment model.

RESULTS.

Of 18,190 women, 78 (0.43%) had ≥20% lifetime risk of breast cancer, all of whom had ≥10% risk of carrying a BRCA mutation. An additional 374 women (2.06%) had <20% lifetime breast cancer risk but ≥10% risk of mutation. Overall, there were 183 (1%) predicted mutation carriers, 27 women (0.15%) who had ≥20% lifetime risk of breast cancer, and 62 women (0.34%) who had ≥10% risk of mutation but <20% lifetime breast cancer risk.

CONCLUSIONS.

The ACS guidelines for breast MRI screening may systematically exclude MRI screening for many women who have a substantial risk for BRCA mutation. The current results demonstrated a need for greater awareness of breast cancer risk factors in the screening mammography population, so that high‐risk women can be identified and given access to genetic testing and counseling regarding all risk‐reducing interventions. Cancer 2008. © 2008 American Cancer Society.     

Diagnosed with breast cancer while on a family history screening programme: an exploratory qualitative study

Mammographic screening is offered to many women under 50 in the UK who are at moderate or high risk of developing breast cancer because of their family history of the disease. Little is understood about the impact of screening on the emotional well-being of women with a family history of breast cancer. This qualitative study explores the value that women at increased risk placed on screening, both pre- and post-cancer diagnosis and the impact of the diagnosis. In-depth interviews were undertaken with 12 women, aged 35–50, diagnosed with breast cancer while on an annual mammographic screening programme. Women described the strong sense of reassurance gained from screening prior to diagnosis. This faith in screening was reinforced by early detection of their cancer. Reactions to diagnosis ranged from devastation to relief at having finally developed a long-expected condition. Despite their positive attitudes about screening, not all women wanted to continue with surveillance. For some, prophylactic mastectomy was preferable, to reduce future cancer risk and to alleviate anxieties about the detection of another cancer at each subsequent screen. This study illustrates the positive yet diverse attitudes towards mammographic screening in this group of women with a family history of breast cancer.     

Development of a screening tool for the identification of psychooncological treatment need in breast cancer patients

Objective: In breast cancer patients the diagnosis, treatment and aftercare of the physical disease cause a large amount of psychosocial distress, which can have a variety of negative consequences on patients' physical and mental well‐being. Although about one‐third of the patients show heightened psychosocial distress that may require psychooncological interventions its detection in daily clinical routine is poor and referral to mental health professionals is insufficient. The aim of the study was to develop a short screening tool for the detection of need for psychooncological treatment (POT) in breast cancer patients. Methods: Over a period of six months, 115 breast cancer outpatients attending the Department of Gynaecology at Innsbruck Medical University were consecutively included in the study. Logistic regression analysis and ROC analyses were used to identify the most predictive item set from a set of questionnaires (EORTC‐QLQ‐C30, HADS and Hornheide Screening Instrument) and other additional questions. Results: Data from 105 breast cancer patients (mean age 58.8, SD 12.3) were available for analysis. A logistic regression equation containing the EORTC‐QLQ‐C30 scales Emotional Functioning and Role Functioning as well as the yes–no question after psychiatric/psychological/psychotherapeutic treatment at any point in lifetime showed highest predictive power with regard to need of POT (AUC=0.88; CI 95% 0.82–0.95). A pilot study (n=20) investigating applicability of a computerized version of this screening tool in oncological routine showed high acceptance and feasibility. Conclusion: The developed PO‐screening tool showed high diagnostic accuracy regarding POT needs. The short assessment time and good usability of its computerized version allowed easy implementation in daily oncological routine. Copyright © 2009 John Wiley & Sons, Ltd.